An integrated intervention to reduce intimate partner violence in pregnancy: a randomized controlled trial

Effectiveness of a counselling intervention implemented in antenatal setting for pregnant women facing domestic violence: a pre-experimental study

OBJECTIVE

To assess the effectiveness of a counselling intervention in antenatal care settings for pregnant women who report domestic violence.

DESIGN

Pre-experimental study with pretest-posttest design.

SETTINGS

Two public hospitals in Mumbai, India.

SAMPLE

In all, 2778 pregnant women accessing antenatal care (ANC) in the hospitals from February to November 2016 were approached for study participation; 2515 women consented. These women were screened by trained counsellors for domestic violence during pregnancy (domestic violence during pregnancy). Domestic violence during pregnancy was reported by 16.2% (408) of women. Of these, 155 women sought counselling services. Post-intervention analyses were carried out with 142 women at 6 weeks post-delivery; 13 women were not contactable.

METHODS

The 442 women who reported domestic violence during pregnancy were provided a minimum of two counselling sessions by trained counsellors during their ANC visits. A counselling intake form was used to collect pre- and post-intervention data.

MAIN OUTCOME MEASURES

Prevalence of domestic violence during pregnancy, change in women's ability to cope, safety, and health.

RESULTS

Prevalence of domestic violence during pregnancy (16.1%) was comparable to those of common obstetric complications routinely screened for during ANC. In all, 60-65% women reported cognitive changes such as recognising impact of violence and need to speak out against it. In all, 50.7% women took action at the individual level to address domestic violence during pregnancy. This change was not statistically significant (P-value 0.193). Of the women studied, 35.9% adopted at least one safety measure, and 84% of the women reported better health status post-intervention.

CONCLUSIONS

Routine enquiry and counselling for domestic violence during pregnancy are effective in improving women's ability to cope, safety, and health.

FUNDING

This study was funded by The John D. and Catherine T. MacArthur Foundation.

TWEETABLE ABSTRACT

Improving coping strategies, safety and health of pregnant women who reported domestic violence by providing counselling in antenatal care setting.

Linking partner violence survivors to supportive services: impact of the M Health Community Network project on healthcare utilization

BACKGROUND

Intimate partner violence (IPV) is associated with adverse health effects and increased healthcare utilization. Systems-level interventions have been shown to be effective in identifying and referring survivors but little is known about how these strategies impact future utilization. The objective of this study is to examine the impact of a systems-level response on healthcare utilization among patients screening positive for IPV from November 2016 to February 2019 in a large multi-specialty outpatient health system in the Midwest.

METHODS

Using electronic health record (EHR) data, we identified patients who screened positive for IPV (N = 756) and categorized their response as accepted printed material (N = 116), accepted direct referrals (N = 85), declined both (N = 271), or missing (N = 255). We used negative binomial models to model post-period utilization as a function of decision group, pre-period utilization, and clinical and demographic factors.

RESULTS

After controlling for demographic characteristics and baseline utilization, the printed materials and direct referral groups had higher utilization rates than those who declined printed materials and direct referral during the post-period for every type of service. However, these differences were only statistically significant for outpatient, behavioral health, and social work services. Specifically, the visit rate for patients receiving printed materials was two times higher (rate ratio: 2.18; 95% CI: 1.21, 3.94) for behavioral health services and three times higher (rate ratio: 3.33; 95% CI: 1.3, 8.52) for social work services compared to those who refused printed material and direct referral. For those opting for a direct referral, the visit rate was two times higher for outpatient services (rate ratio: 1.97; 95% CI: 1.13, 3.42) compared to those who refused.

CONCLUSIONS

Patients receiving printed materials or direct referrals had more social work and behavioral health visits, highlighting an important outcome of the protocol. However, higher utilization rates among outpatient services and a trend toward higher utilization of other services, including the emergency department, suggest greater health service utilization is not diminished by the systems level response-at least not within a two-year time frame.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

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

A randomized controlled trial of a computer-based brief intervention for victimized perinatal women seeking mental health treatment

Intimate partner victimization (IPV) during the perinatal period is associated with adverse outcomes for the woman, her developing fetus, and any children in her care. Maternal mental health concerns, including depression and anxiety, are prevalent during the perinatal period particularly among women experiencing IPV. Screening and interventions for IPV targeting women seeking mental health treatment are lacking. In the current study, we examine the feasibility, acceptability, and the preliminary efficacy of a brief, motivational computer-based intervention, SURE (Strength for U in Relationship Empowerment), for perinatal women with IPV seeking mental health treatment. The study design was a two-group, randomized controlled trial with 53 currently pregnant or within 6-months postpartum women seeking mental health treatment at a large urban hospital-based behavioral health clinic for perinatal women. Findings support the acceptability and feasibility of the SURE across a number of domains including content, delivery, and retention. All participants (100%) found the information and resources in SURE to be helpful. Our preliminary results found the degree of IPV decreased significantly from baseline to the 4-month follow-up for the SURE condition (paired t-test, p < 0.001), while the control group was essentially unchanged. Moreover, there was a significant reduction in emotional abuse for SURE participants (p = 0.023) relative to participants in the control condition. There were also reductions in physical abuse although non-significant (p = 0.060). Future work will test SURE in a larger, more diverse sample. ClinicalTrials.gov Identifier: NCT02370394.

Counselling-based psychosocial intervention to improve the mental health of abused pregnant women: a protocol for randomised controlled feasibility trial in a tertiary hospital in eastern Nepal

INTRODUCTION

The strong correlation between domestic and family violence (DFV) and mental health has been well documented in studies. Pregnancy is a period when both DFV and mental distress tend to occur and/or accentuate. Although limited, available evidence from developed countries has shown continual support and education as psychological first aid that can reduce DFV and improve mental health. However, there is significantly less number of studies from resource-constrained countries; thus, there continues to be a substantial gap in knowledge and awareness regarding effective interventions for DFV.

METHODS AND ANALYSIS

A two-arm randomised trial with a nested qualitative study has been planned to assess feasibility and treatment effect estimates of a counselling-based psychosocial intervention among pregnant women with a history of abuse. A total of 140 pregnant women who meet the inclusion criteria will be recruited into the study. Block randomisation will be used to allocate women equally into two groups. The intervention group will receive a counselling session, an information booklet and continuous support by a researcher, while women in the control group will receive contact information of local support services. Feasibility measures, such as rates of recruitment, consent and retention, will be calculated. Qualitative interviews with participants and healthcare providers will explore the acceptability and usability of the intervention. Outcome measures, such as psychological distress, quality of life, social support and self-efficacy, will be measured at baseline, 4 weeks postintervention and 6 weeks postpartum.

ETHICS AND DISSEMINATION

This study has obtained ethical approval from the Griffith University Human Research Ethics Committee, the Nepal Health Research Council and the Institutional Review Board of a tertiary hospital in Dharan, Nepal. The findings will be disseminated via peer-reviewed publications and conference presentations and will be used to inform a future multicentre trial.

TRIAL REGISTRATION NUMBER

12618000307202; Pre-results.

Interventions for reducing and/or controlling domestic violence among pregnant women in low- and middle-income countries: a systematic review

BACKGROUND

Domestic violence (DV) during pregnancy is recognized as a global health problem associated with serious health consequences for both the mother and her baby. Several interventions aimed at addressing DV around the time of pregnancy have been developed in the last decade, but they are primarily from developed countries. Low- and middle-income countries (LMICs) are facing both a mounting burden of DV as well as severe resource constraints that keep them from emulating some of the effective interventions implemented in developed settings. A systematic review was conducted to examine the approaches and effects of interventions designed for reducing or controlling DV among pregnant women in LMICs.

METHODS

Electronic databases were systematically searched, and the search was augmented by bibliographic reviews and expert consultations. Two reviewers assessed eligibility and quality of the studies and extracted data independently. The third reviewer was involved to resolve any discrepancies between the reviewers. Due to the limited number of studies and varied outcomes, a meta-analysis was not possible. Primary outcomes of this review included frequency and/or severity of DV and secondary outcomes included mental health, safety behaviours, and use of community resources. In addition, findings from the critical appraisal of studies were utilised to inform the initial draft of Theory of Change (ToC).

RESULTS

Only five studies (two randomized trials and three non-randomized trials) met the eligibility criteria. The interventions consisting of supportive counselling demonstrated a reduction in DV and an improvement in use of safety behaviours. One study has embedded the DV intervention into an existing program on human immunodeficiency virus (HIV). Limited evidence could be drawn for outcomes such as quality of life and the use of community resources.

DISCUSSION

This review attempted to address the knowledge gap by collating evidence on interventions aimed at addressing DV among pregnant women in LMICs. The development of a ToC was critical in understanding how certain activities led to the desired outcomes. This ToC can guide the design of future research and development of practice guidelines. The participatory involvement of the stakeholders is recommended to refine the current ToC to support its further development for practice.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42017073938.

An Intimate Partner Violence Prevention Intervention in a Nurse Home Visitation Program: A Randomized Clinical Trial

BACKGROUND

Intimate partner violence (IPV) is a significant public health problem with many negative consequences, particularly for pregnant women. This randomized trial investigated the effectiveness of an IPV preventive intervention embedded within the Nurse Family Partnership (NFP) program.

MATERIALS AND METHODS

Participants enrolled over a 20-month period and were interviewed at baseline and 1- and 2-year follow-up. Eligibility criteria included first pregnancy, eligible for the nutrition program Women, Infants, and Children (WIC), English or Spanish speaking, and at least 15 years of age. All women initially referred and screened were randomized to either intervention (NFP+) or control (NFP only) condition. The final sample consisted of 238 women completing baseline assessments; retention was 81% at 2-year follow-up.

RESULTS

Analyses indicated that there were no main effects: the intervention affected participants differently depending on their baseline experience with IPV. For physical violence victimization, an interaction between baseline victimization and treatment was found; the intervention reduced victimization at 1 year (and approached significance at 2 years), but only among women who had not experienced past-year physical victimization at baseline. For sexual violence victimization, another interaction emerged; women in the intervention group were more likely to report sexual violence victimization at 2-year follow-up, but only among participants who had reported sexual victimization at baseline. The only effect on IPV perpetration was psychological perpetration at 2-year follow-up; again, the treatment effect was moderated by baseline perpetration. The intervention reduced psychological perpetration for participants who were nonperpetrators at baseline, but had no effect on those reporting perpetration.

CONCLUSIONS

Overall, findings suggest that the intervention was effective in reducing some forms of violence among those not experiencing IPV at baseline, but was ineffective or potentially harmful for those already experiencing IPV.

Screening for Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Intimate partner violence (IPV), elder abuse, and abuse of vulnerable adults are common and result in adverse health outcomes.

OBJECTIVE

To review the evidence on screening and interventions for IPV, elder abuse, and abuse of vulnerable adults to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, Cochrane Library, EMBASE, and trial registries through October 4, 2017; references; experts; literature surveillance through August 1, 2018.

STUDY SELECTION

English-language randomized clinical trials (RCTs), studies evaluating test accuracy, and cohort studies with a concurrent control group assessing harms.

DATA EXTRACTION AND SYNTHESIS

Dual review of titles and abstracts, full-text articles, and study quality; qualitative synthesis of findings. Data were not pooled, primarily because of heterogeneity of populations, interventions, and outcomes.

MAIN OUTCOMES AND MEASURES

Abuse or neglect, morbidity caused by abuse, test accuracy, and harms.

RESULTS

Thirty studies were included (N = 14 959). Three RCTs (n = 3759) compared IPV screening with no screening; none found significant improvements in outcomes (eg, IPV or quality of life) over 3 to 18 months and 2 (n = 935) reported no harms of screening. Nine studies assessed tools to detect any past-year or current IPV in women; for past-year IPV (5 studies [n = 6331]), sensitivity of 5 tools ranged from 65% to 87% and specificity ranged from 80% to 95%. The accuracy of 5 tools (4 studies [n = 1795]) for detecting current abuse varied widely; sensitivity ranged from 46% to 94% and specificity ranged from 38% to 95%. Eleven RCTs (n = 6740) evaluated interventions for women with screen-detected IPV. Two enrolling pregnant women (n = 575) found significantly less IPV among women in the intervention group: 1 home visiting intervention (standardized mean difference [SMD], -0.34 [95% CI, -0.59 to -0.08]) and 1 behavioral counseling intervention for multiple risks (IPV, smoking, depression, tobacco exposure) (SMD, -0.40 [95% CI, -0.68 to -0.12]). No studies evaluated screening or interventions for elder abuse or abuse of vulnerable adults. One study assessing a screening tool for elder abuse had poor accuracy (sensitivity, 46% and specificity, 73% for detecting physical or verbal abuse).

CONCLUSIONS AND RELEVANCE

Although available screening tools may reasonably identify women experiencing IPV, trials of IPV screening in adult women did not show a reduction in IPV or improvement in quality of life over 3 to 18 months. Limited evidence suggested that home visiting and behavioral counseling interventions that address multiple risk factors may lead to reduced IPV among pregnant or postpartum women. No studies assessed screening or treatment for elder abuse and abuse of vulnerable adults.

Screening for Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: US Preventive Services Task Force Final Recommendation Statement

IMPORTANCE

Intimate partner violence (IPV) and abuse of older or vulnerable adults are common in the United States but often remain undetected. In addition to the immediate effects of IPV, such as injury and death, there are other health consequences, many with long-term effects, including development of mental health conditions such as depression, posttraumatic stress disorder, anxiety disorders, substance abuse, and suicidal behavior; sexually transmitted infections; unintended pregnancy; and chronic pain and other disabilities. Long-term negative health effects from elder abuse include death, higher risk of nursing home placement, and adverse psychological consequences.

OBJECTIVE

To update the US Preventive Services Task Force (USPSTF) 2013 recommendation on screening for IPV, elder abuse, and abuse of vulnerable adults.

EVIDENCE REVIEW

The USPSTF commissioned a review of the evidence on screening for IPV in adolescents, women, and men; for elder abuse; and for abuse of vulnerable adults.

FINDINGS

The USPSTF concludes with moderate certainty that screening for IPV in women of reproductive age and providing or referring women who screen positive to ongoing support services has a moderate net benefit. There is adequate evidence that available screening instruments can identify IPV in women. The evidence does not support the effectiveness of brief interventions or the provision of information about referral options in the absence of ongoing supportive intervention components. The evidence demonstrating benefit of ongoing support services is predominantly found in studies of pregnant or postpartum women. The benefits and harms of screening for elder abuse and abuse of vulnerable adults are uncertain, and the balance of benefits and harms cannot be determined.

CONCLUSIONS AND RECOMMENDATION

The USPSTF recommends that clinicians screen for IPV in women of reproductive age and provide or refer women who screen positive to ongoing support services. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for abuse and neglect in all older or vulnerable adults. (I statement).

The relationship between vaginal ring use and intimate partner violence and social harms: formative research outcomes from the CHARISMA study in Johannesburg, South Africa

Despite being designed for autonomous use, research suggests partner approval is often in women's microbicide use. Microbicide study participants have described many ways product use affects relationships, from improving sexual pleasure to increasing harm, including exacerbating intimate partner violence (IPV). As the dapivirine ring proceeds closer to licensure, supporting women's agency to use microbicides safely is a priority. We conducted 42 in-depth interviews with former participants of the Microbicide Trials Network (MTN)-020 trial of the dapivirine vaginal ring and their male partners in Johannesburg, South Africa, to explore how ring use and partnership dynamics interacted. We sampled women who reported harms or partner non-support and women with supportive partners. Male and female narratives revealed high background levels of IPV. Women described how study participation/ring use exacerbated violence, and for a few couples served as a rationale for additional abuse. In response, women described feeling powerless and fearful of conflict, resulting in product nonuse. For one participant violence was reduced, and for several others, empowerment was sparked. These findings suggest future providers have the opportunity to shift more women from a place of fear/violence to one of safety/empowerment through the integration of IPV screening and relationship counselling.

Surveillance for Violent Deaths - National Violent Death Reporting System, 27 States, 2015

PROBLEM/CONDITION

In 2015, approximately 62,000 persons died in the United States as a result of violence-related injuries. This report summarizes data from CDC's National Violent Death Reporting System (NVDRS) regarding violent deaths from 27 U.S. states for 2015. Results are reported by sex, age group, race/ethnicity, location of injury, method of injury, circumstances of injury, and other selected characteristics.

REPORTING PERIOD

2015.

DESCRIPTION OF SYSTEM

NVDRS collects data regarding violent deaths obtained from death certificates, coroner/medical examiner reports, law enforcement reports, and secondary sources (e.g., child fatality review team data, supplemental homicide reports, hospital data, and crime laboratory data). This report includes data from 27 states that collected statewide data for 2015 (Alaska, Arizona, Colorado, Connecticut, Georgia, Hawaii, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Vermont, Virginia, and Wisconsin). NVDRS collates documents for each death and links deaths that are related (e.g., multiple homicides, a homicide followed by a suicide, or multiple suicides) into a single incident.

RESULTS

For 2015, NVDRS captured 30,628 fatal incidents involving 31,415 deaths in the 27 states included in this report. The majority (65.1%) of deaths were suicides, followed by homicides (23.5%), deaths of undetermined intent (9.5%), legal intervention deaths (1.3%) (i.e., deaths caused by law enforcement and other persons with legal authority to use deadly force, excluding legal executions), and unintentional firearm deaths (<1.0%). (The term "legal intervention" is a classification incorporated into the International Classification of Diseases, Tenth Revision [ICD-10] and does not denote the lawfulness or legality of the circumstances surrounding a death caused by law enforcement.) Demographic patterns varied by manner of death. Suicide rates were highest among males, non-Hispanic American Indian/Alaska Natives, non-Hispanic whites, adults aged 45-54 years, and men aged ≥75 years. The most common method of injury was a firearm. Suicides often were preceded by a mental health, intimate partner, substance abuse, or physical health problem, or a crisis during the previous or upcoming 2 weeks. Homicide rates were higher among males and persons aged <1 year and 20-34 years. Among males, non-Hispanic blacks accounted for the majority of homicides and had the highest rate of any racial/ethnic group. Homicides primarily involved a firearm, were precipitated by arguments and interpersonal conflicts, were related to intimate partner violence (particularly for females), or occurred in conjunction with another crime. When the relationship between a homicide victim and a suspected perpetrator was known, an acquaintance/friend or an intimate partner frequently was involved. Legal intervention death rates were highest among males and persons aged 20-54 years; rates among non-Hispanic black males were approximately double the rates of those among non-Hispanic white males. Precipitating circumstances for legal intervention deaths most frequently were an alleged criminal activity in progress, the victim reportedly using a weapon in the incident, a mental health or substance abuse problem (other than alcohol abuse), an argument or conflict, or a recent crisis (during the previous or upcoming 2 weeks). Unintentional firearm deaths were more frequent among males, non-Hispanic whites, and persons aged 10-24 years; these deaths most often occurred while the shooter was playing with a firearm and most often were precipitated by a person unintentionally pulling the trigger or mistakenly thinking the firearm was unloaded. Deaths of undetermined intent were more frequent among males, particularly non-Hispanic black and American Indian/Alaska Native males, and persons aged 30-54 years. Substance abuse, mental health problems, physical health problems, and a recent crisis were the most common circumstances preceding deaths of undetermined intent. In 2015, approximately 3,000 current or former military personnel died by suicide. The majority of these decedents were male, non-Hispanic white, and aged 45-74 years. Most suicides among military personnel involved a firearm and were precipitated by mental health, physical health, and intimate partner problems, as well as a recent crisis.

INTERPRETATION

This report provides a detailed summary of data from NVDRS for 2015. The results indicate that deaths resulting from self-inflicted or interpersonal violence most frequently affect males and certain age groups and minority populations. Mental health problems, intimate partner problems, interpersonal conflicts, and general life stressors were primary precipitating events for multiple types of violent deaths, including suicides among current or former military personnel.

PUBLIC HEALTH ACTION

NVDRS data are used to monitor the occurrence of violence-related fatal injuries and assist public health authorities in the development, implementation, and evaluation of programs and policies to reduce and prevent violent deaths. For example, Virginia VDRS data are used to help identify suicide risk factors among active duty service members, Oregon VDRS suicide data are used to coordinate information and activities across community agencies that support veterans and active duty service members, and Arizona VDRS data are used to develop recommendations for primary care providers who deliver care to veterans. The continued development and expansion of NVDRS to include all 50 states, U.S. territories, and the District of Columbia are essential to public health efforts to reduce deaths due to violence.

Opportunistic domestic violence screening for pregnant and post-partum women by community based health care providers

Background

Domestic violence against women is a global endemic that can commence or escalate during pregnancy and continue postpartum. Pregnant and postpartum women generally access health care providers more at this time than at any other time in their lives. Despite this, little is known about primary health care providers’ screening practices for domestic violence. The purpose of this paper is to present survey findings that identified domestic violence screening practices of community based health care providers in pregnant and postpartum women.

Methods

This paper reports on the survey results of a larger sequential mixed methods study that involved a survey and semi-structured interviews, and used a pragmatic approach to the data collection and analysis. The survey sought information via both fixed choice and open responses. Quantitative data from the surveys were entered into the Statistical Package for Social Science (SPSS™ Version 22) and analysed using descriptive statistics. Open responses were collated and then integrated and presented with the quantitative data.

Results

Results revealed that some health care providers did not screen for domestic violence. Factors contributing to this lack of screening included: a lack of recognition that this was part of their role; and a lack of domestic violence screening policies and/or reminder systems. Further barriers to domestic violence screening were identified as a lack of time, resources and confidence in undertaking the screening and referral of women when domestic violence was detected.

Conclusions

The findings reported in this paper confirm that further insights into the domestic violence screening practices of community based health care providers is required. Findings also have the potential to inform interventions that can be implemented to increase domestic violence screening and promote appropriate referral practices.

Electronic supplementary material

The online version of this article (10.1186/s12905-018-0620-2) contains supplementary material, which is available to authorized users.

The effect of training problem-solving skills for pregnant women experiencing intimate partner violence: a randomized control trial

Introduction

Intimate partner violence (IPV) in pregnancy is considered as an additional threat to the maternal/fetal health. The present study was aimed to investigate the effectiveness of training problem-solving skills on IPV against pregnant women.

Methods

The present randomized clinical trial was conducted on 125 and 132 women visiting the health centers of Tehran as the intervention and the control groups, respectively; samples were selected using random stratified cluster sampling. The intervention group underwent four problem-solving training sessions. Three months later, both groups completed the revised Conflict Tactics Scale questionnaire. Data were analyzed using SPSS v.16.

Results

The mean (SD) ages of the participants were 27.51 (4.26) and 27.02 (4.26) years, respectively, in the control and the intervention groups. The rates of the physical and psychological violence were significantly reduced after the intervention in the intervention group. Risk differences of the physical, psychological and sexual violence before and after the intervention were 3% (95% CI: -8.23 to14.13, P = 0.6), 1.5% (95% CI: -4.93 to 8.03, P = 0.6) and 4.8% (95% CI: -7.11 to 16.52, P = 0.4) in the control group and 8.8% (95% CI: -3.47 to 20.71, P = 0.1), 25.4% (95% CI: 15.77 to 34.66, P < 0.001) and 4.9% (95% CI: -7.38 to16.97, P = 0.4) in the intervention group, respectively.

Conclusion

It seems that training this skill as a part of the routine prenatal care could be effective in reducing intimate partner violence.

Surveillance for Violent Deaths - National Violent Death Reporting System, 18 States, 2014

PROBLEM/CONDITION

In 2014, approximately 59,000 persons died in the United States as a result of violence-related injuries. This report summarizes data from CDC's National Violent Death Reporting System (NVDRS) regarding violent deaths from 18 U.S. states for 2014. Results are reported by sex, age group, race/ethnicity, marital status, location of injury, method of injury, circumstances of injury, and other selected characteristics.

REPORTING PERIOD COVERED

2014.

DESCRIPTION OF SYSTEM

NVDRS collects data from participating states regarding violent deaths. Data are obtained from death certificates, coroner/medical examiner reports, law enforcement reports, and secondary sources (e.g., child fatality review team data, supplemental homicide reports, hospital data, and crime laboratory data). This report includes data from 18 states that collected statewide data for 2014 (Alaska, Colorado, Georgia, Kentucky, Maryland, Massachusetts, Michigan, New Jersey, New Mexico, North Carolina, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Virginia, and Wisconsin). NVDRS collates documents for each death and links deaths that are related (e.g., multiple homicides, a homicide followed by a suicide, or multiple suicides) into a single incident.

RESULTS

For 2014, a total of 22,098 fatal incidents involving 22,618 deaths were captured by NVDRS in the 18 states included in this report. The majority of deaths were suicides (65.6%), followed by homicides (22.5%), deaths of undetermined intent (10.0%), deaths involving legal intervention (1.3%) (i.e., deaths caused by law enforcement and other persons with legal authority to use deadly force, excluding legal executions), and unintentional firearm deaths (<1%). The term "legal intervention" is a classification incorporated into the International Classification of Diseases, Tenth Revision (ICD-10) and does not denote the lawfulness or legality of the circumstances surrounding a death caused by law enforcement. Suicides occurred at higher rates among males, non-Hispanic American Indian/Alaska Natives (AI/AN), non-Hispanic whites, persons aged 45-54 years, and males aged ≥75 years. Suicides were preceded primarily by a mental health, intimate partner, substance abuse, or physical health problem or a crisis during the previous or upcoming 2 weeks. Homicide rates were higher among males and persons aged <1 year and 15-44 years; rates were highest among non-Hispanic black and AI/AN males. Homicides primarily were precipitated by arguments and interpersonal conflicts, occurrence in conjunction with another crime, or related to intimate partner violence (particularly for females). When the relationship between a homicide victim and a suspected perpetrator was known, it was most often either an acquaintance/friend or an intimate partner. Legal intervention death rates were highest among males and persons aged 20-44 years; rates were highest among non-Hispanic black males and Hispanic males. Precipitating factors for the majority of legal intervention deaths were alleged criminal activity in progress, the victim reportedly using a weapon in the incident, a mental health or substance abuse problem, an argument or conflict, or a recent crisis. Deaths of undetermined intent occurred more frequently among males, particularly non-Hispanic black and AI/AN males, and persons aged 30-54 years. Substance abuse, mental health problems, physical health problems, and a recent crisis were the most common circumstances preceding deaths of undetermined intent. Unintentional firearm deaths were more frequent among males, non-Hispanic whites, and persons aged 10-24 years; these deaths most often occurred while the shooter was playing with a firearm and were most often precipitated by a person unintentionally pulling the trigger or mistakenly thinking the firearm was unloaded.

INTERPRETATION

This report provides a detailed summary of data from NVDRS for 2014. The results indicate that violent deaths resulting from self-inflicted or interpersonal violence disproportionately affected persons aged <65 years, males, and certain minority populations. The primary precipitating factors for homicides and suicides were intimate partner problems, interpersonal conflicts, mental health and substance abuse problems, and recent crises.

PUBLIC HEALTH ACTION

NVDRS data are used to monitor the occurrence of violence-related fatal injuries and assist public health authorities in the development, implementation, and evaluation of programs and policies to reduce and prevent violent deaths. For example, North Carolina VDRS data were used to improve case ascertainment of pregnancy-associated suicides, Wisconsin VDRS data were used to develop the statewide suicide prevention strategy, and Colorado VDRS data were used to develop programs and prevention strategies for suicide among veterans. The continued development and expansion of NVDRS to include all U.S. states, territories, and the District of Columbia are essential to public health efforts to reduce the impact of violence.

A psychosocial intervention to reduce gender-based violence and antepartum depressive symptoms in pregnant women in Kisumu County, Kenya: a quasi-experimental study

Introduction

Gender-based violence during pregnancy and its associated adverse health effects are disproportionately higher in developing countries like Kenya where screening for and management of gender-based violence is currently not part of routine antenatal care. This study assessed the effect of a psychosocial intervention on gender-based violence and antepartum depressive symptoms in pregnant women.

Methods

This quasi-experimental study compared gender-based violence and antepartum depression scores of 288 pregnant women in the two arms; one exposed to a psychosocial intervention and another receiving usual antenatal care. We used analysis of covariance to estimate the intervention effect and Chi-square to test the equality of proportions.

Results

The difference between the psychosocial intervention and the usual antenatal care group in the total intimate partner violence and physical violence scores was a significant, with small effect sizes of partial eta = 0.196 and 0.305 respectively. The two arms did not differ in terms of the proportion of women reporting other acts of gender-based violence by intimate and non-intimate partners post-intervention. The intervention group had significantly lower mean depression scores compared to the usual care group, post-intervention, with a medium effect size of 0.500.

Conclusion

This intervention aimed at reduction of gender-based violence and improvement of mental health of pregnant women is promising. Primary health care facilities in resource-constrained settings can take advantage of local capacity to deliver focused non-specialized psychosocial support to pregnant women experiencing violence.

Interventions for domestic violence among pregnant women in low- and middle-income countries: a systematic review protocol

BACKGROUND

Violence during pregnancy is a global problem, associated with serious health risks for both the mother and baby. Evaluation of interventions targeted for reducing or controlling domestic violence (DV) is still in its infancy, and the majority of findings are primarily from high-income countries (HICs). Therefore, there is an urgent need for generating evidence of DV interventions among pregnant women in low- and middle-income countries (LMICs).

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines will be employed to structure the review. A comprehensive search will be carried out via electronic databases including MEDLINE, CINAHL, Scopus, Embase, Web of Science, PsycINFO, and The Cochrane library. Gray literature will also be scrutinized for potential articles. An optimal search strategy has been developed following consultations with subject-matter experts and librarians. This search strategy will be adapted to the different databases. Experimental studies evaluating DV interventions among pregnant women from LMICs will be included in the review. The review will only include literature written in English. Two reviewers will independently screen and assess studies for inclusion in the review. A third author will resolve any discrepancies between the reviewers. Risk of bias will be assessed based on the Cochrane risk of bias assessment tool, and overall quality of the evidence will be judged using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria. Findings will be presented with the narrative synthesis, and if applicable, they will be further quantified using random-effects meta-analysis. Effect size, risk ratio for dichotomous variables, and standardized mean differences for continuous variables will be calculated for each outcome using Review Manager 5.3.

DISCUSSION

Systematic reviews to evaluate the efficacy of interventions to address DV within the perinatal context have been limited. Hence, no one intervention has emerged as substantially effective towards addressing perinatal DV and associated health consequences. The evidence generated from this systematic review will inform researchers and policy makers about the effectiveness of existing DV interventions among pregnant women in LMICs and provide recommendations for future research in this area. This in turn will contribute towards violence prevention in LMICs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017073938.

Outcome Measures for Evaluating Intimate Partner Violence Programs Within Clinical Settings: A Systematic Review of the Literature

BACKGROUND

Multiple intimate partner violence (IPV) identification and assistance programs have been implemented across clinical settings. The results of these studies are inconclusive and frequently conflicting, resulting in clinical uncertainty and controversy regarding the merits of IPV identification and assistance programs. We aimed to describe the choice of outcome measures used in previously published randomized trials of IPV identification and assistance programs.

METHOD

A comprehensive literature search was conducted in the Medline, Embase, PyscInfo, and CENTRAL databases. The outcomes assessed in each included study were extracted and categorized, and the methodological quality of each eligible study was assessed using the Cochrane Risk of Bias tool.

RESULTS

Of 20 eligible studies, 6 evaluated IPV identification programs and 14 studies examined IPV assistance programs. The included studies used 48 different outcomes that we classified into 10 categories. For identification studies, the most commonly used outcome categories were IPV disclosure (66.7%) and resource use (66.7%). The most commonly used outcome categories for the IPV assistance studies included IPV recurrence and severity (64.3%) and health outcomes (50%). The included studies demonstrated a number of methodological limitations as identified by the Cochrane Risk of Bias instrument.

CONCLUSIONS

IPV identification and assistance programs are evaluated using many different outcome measures. Although this diversity enriches the IPV literature, it makes it challenging to compare studies. The results of this review highlight the challenges of conducting research in the field of IPV and the complexity of selecting, measuring, and interpreting outcomes.

Implementation of a Brief Abuse and Basic Needs Tool: Impact on Utilization of Social Services in Ambulatory Medical Clinics

Domestic violence (DV) screening has become increasingly common in recent years; however, many organizations still do not practice universal screening, and there is considerable debate concerning the best screening tool for detecting DV. The current research suggests that a brief tool would be ideal and that existing brief tools are comparable to more extensive instruments. Per Joint Commission standards, the ambulatory clinics at West Virginia University Hospitals instituted the use of the Functional Health Screening (FHS), a three-item tool that screens for unexplained weight changes, DV, and basic needs deficits. This tool is administered at the beginning of every outpatient clinic visit. This study includes a retrospective chart review to investigate the detection rate of this tool for DV and basic needs deficits, the increased utilization of social services, and nursing attitudes concerning FHS.

The impact of a referral card-based intervention on intimate partner violence, psychosocial health, help-seeking and safety behaviour during pregnancy and postpartum: a randomized controlled trial

Background

We aimed to investigate the impact of a referral-based intervention in a prospective cohort of women disclosing intimate partner violence (IPV) on the prevalence of violence, and associated outcomes psychosocial health, help-seeking and safety behaviour during and after pregnancy.

Methods

Women seeking antenatal care in eleven Belgian hospitals were consecutively invited from June 2010 to October 2012, to participate in a single-blind randomized controlled trial (RCT) and handed a questionnaire. Participants willing to be interviewed and reporting IPV victimisation were randomised. In the Intervention Group (IG) participants received a referral card with contact details of services providing assistance and tips to increase safety behaviour. Participants in the Control Group (CG) received a “thank you” card. Follow-up data were obtained through telephone interview at an average of 10 months after receipt of the card.

Results

At follow-up (n = 189), 66.7% (n = 126) of the participants reported IPV victimisation. Over the study-period, the prevalence of IPV victimisation decreased by 31.4% (P < 0.001), psychosocial health increased significantly (5.4/140, P < 0.001), 23.8% (n = 46/193) of the women sought formal help, 70.5% (n = 136/193) sought informal help, and 31.3% (n = 60/192) took at least one safety measure. We observed no statistically significant differences between the IG and CG, however. Adjusted for psychosocial health at baseline, the perceived helpfulness of the referral card seemed to be larger in the IG. Both the questionnaire and the interview were perceived to be significantly more helpful than the referral card itself (P < 0.001).

Conclusions

Asking questions can be helpful even for types of IPV of low severity, although simply distributing a referral card may not qualify as the ideal intervention. Future interventions should be multifaceted, delineate different types of violence, controlling for measurement reactivity and designing a tailored intervention programme adjusted to the specific needs of couples experiencing IPV.

Trial registration

The trial was registered with the U.S. National Institutes of Health ClinicalTrials.gov registry on July 6, 2010 under identifier NCT01158690).

Electronic supplementary material

The online version of this article (10.1186/s12884-017-1519-x) contains supplementary material, which is available to authorized users.

Healthcare Access and Cancer Screening Among Victims of Intimate Partner Violence

BACKGROUND

Intimate partner violence (IPV) victims often experience substantial and persistent mental and physical health problems, including increased risk for chronic disease and barriers to healthcare access. This study investigated the association between IPV and cancer screening.

MATERIALS AND METHODS

Behavioral Risk Factor Surveillance System data from the eight states and one U.S. territory that administered the optional IPV module in 2006 were analyzed to examine demographic characteristics, health behaviors, health status, healthcare coverage, use of health services, and cancer screening among men and women who reported IPV victimization compared with those among men and women who did not. IPV victimization included physical violence, threats, and sexual violence.

RESULTS

In the nine jurisdictions that administered the IPV module, 23.6% of women and 11.3% of men experienced IPV. Fewer women and men reporting IPV victimization had health insurance, a personal doctor or healthcare provider, or regular checkups within the past 2 years than nonvictims. More male and female IPV victims were current tobacco users and engaged in binge drinking in the past month. IPV victims of both sexes also had poorer health status, lower life satisfaction, less social and emotional support, and more days with poor physical and mental health in the past month than nonvictims. IPV victimization was associated with lower rates of mammography and colorectal cancer screening but not cervical cancer screening in women and was not associated with colorectal cancer screening in men. In multivariable logistic regression results presented as adjusted proportions controlling for demographics, health status, and healthcare access, only the association with mammography screening remained significant, and the magnitude of this association was modest.

CONCLUSIONS

There were consistent differences between IPV victims and nonvictims in nearly every measure of healthcare access, health status, and preventive service use. Much of this association seems explained by population characteristics associated with both IPV and lower use of preventive service use, including differences in demographic characteristics, health status, and healthcare access. Healthcare providers could take steps to identify populations at high risk for lack of access or use of preventive services and IPV victimization.

Intimate partner violence and pregnancy: screening and intervention

In the first part of this review, we provided currently accepted definitions of categories and subcategories of intimate partner violence and discussed the prevalence and health impacts of intimate partner violence in nonpregnant and pregnant women. Herein we review current recommendations for intimate partner violence screening and the evidence surrounding the effectiveness of intimate partner violence interventions. Screening for intimate partner violence may include exclusively identification of victims of intimate partner violence or both the identification of and intervention for victims. Until recently, many professional organizations did not recommend universal screening for intimate partner violence because of a lack of evidence of effectiveness of screening, lack of evidence demonstrating that screening is not harmful, and/or a lack of consensus regarding the most effective screening tool. The lack of evidence supporting an intervention posed an additional barrier to screening. The American College of Obstetricians and Gynecologists has been a staunch advocate for universal intimate partner violence screening, even when other groups either did not endorse screening or recommended it only for high-risk women. Recent published data confirm that screening is more reliable than usual care in identifying victims of intimate partner violence, both during pregnancy and in nonpregnant women. Likewise, recent published data show that there are no apparent harms of screening for intimate partner violence and that the act of screening may have an empowering effect on women and improve their relationship with and trust in their health care providers. Despite these findings, the implementation rate of intimate partner violence screening remains low. Most encouraging are the recent data showing that interventions performed after screening for intimate partner violence are effective in reducing depression symptoms and episodes of violence as well as improving some outcomes of pregnancy. Although there remains a lack of consensus regarding which screening tool may be the most effective, we exhort all obstetrician-gynecologists to screen all women for intimate partner violence at regular intervals and to familiarize themselves with available community resources to assist those women who have been identified as experiencing intimate partner violence through screening.

Elimination of violence against women and girls as a global action agenda

This article outlines the goals and targets of Sustainable Development Goals (SDGs) related to elimination of violence against women and girls (VAWG) and to explain the framework to target these goals. Prevention of VAWG has been identified as one of the key agents for sustainable development. SDGs gave enough importance and called for the elimination of "all forms of violence against all women and girls everywhere". It identified different social and political enablers of reducing violence which are targeted under different SDGs. This acknowledges tacitly that VAWG is preventable and it is set to prevent and eliminate it. Evidences show that preventing VAWG is possible through multi-sectorial programs. The United Nations committed to revitalized global partnership to mobilize resources for implementing the agenda. Hence, designing and implementing interventions and subsequently scaling-up and intensifying these interventions are required to end VAWG.

Implementation of a Family Planning Clinic-Based Partner Violence and Reproductive Coercion Intervention: Provider and Patient Perspectives

CONTEXT

Despite multiple calls for clinic-based services to identify and support women victimized by partner violence, screening remains uncommon in family planning clinics. Furthermore, traditional screening, based on disclosure of violence, may miss women who fear reporting their experiences. Strategies that are sensitive to the signs, symptoms and impact of trauma require exploration.

METHODS

In 2011, as part of a cluster randomized controlled trial, staff at 11 Pennsylvania family planning clinics were trained to offer a trauma-informed intervention addressing intimate partner violence and reproductive coercion to all women seeking care, regardless of exposure to violence. The intervention sought to educate women about available resources and harm reduction strategies. In 2013, at the conclusion of the trial, 18 providers, five administrators and 49 patients completed semistructured interviews exploring acceptability of the intervention and barriers to implementation. Consensus and open coding strategies were used to analyze the data.

RESULTS

Providers reported that the intervention increased their confidence in discussing intimate partner violence and reproductive coercion. They noted that asking patients to share the educational information with other women facilitated the conversation. Barriers to implementation included lack of time and not having routine reminders to offer the intervention. Patients described how receiving the intervention gave them important information, made them feel supported and less isolated, and empowered them to help others.

CONCLUSIONS

A universal intervention may be acceptable to providers and patients. However, successful implementation in family planning settings may require attention to system-level factors that providers view as barriers.

Current Reports on Perinatal Intimate Partner Violence

PURPOSE OF REVIEW

The purpose of this study was to review the literature on perinatal intimate partner violence, focusing on recent knowledge to guide mental health professionals on the best approaches to identify and treat women exposed to perinatal intimate partner violence.

RECENT FINDINGS

Risk factors have been broadened from individual victim and perpetrator factors to include relationship, community, and societal factors which interact together. Better information is now available on how to identify, document, and treat women exposed to violence around the time of conception, pregnancy, and the postpartum period. Recent information helps psychiatrists and other mental health professionals assist women exposed to violence related to the perinatal period; however, further research is needed to provide improved evidence for optimal interventions for better patient outcomes.

Violence against women and mental health

Violence against women is widely recognised as a violation of human rights and a public health problem. In this Series paper, we argue that violence against women is also a prominent public mental health problem, and that mental health professionals should be identifying, preventing, and responding to violence against women more effectively. The most common forms of violence against women are domestic abuse and sexual violence, and victimisation is associated with an increased risk of mental disorder. Despite clinical guidance on the role of mental health professionals in identifying violence against women and responding appropriately, poor identification persists and can lead to non-engagement with services and poor response to treatment. We highlight that little research has been done on how to improve identification and treatment of victims and perpetrators in contact with mental health services, but that mental health services could play a major role in primary and secondary prevention of violence against women.

What is the role of health systems in responding to domestic violence? An evidence review

Objective The aim of the present study was to review and analyse academic literature and program evaluations to identify promising evidence for health system responses to domestic violence in Australia and internationally. Methods English-language literature published between January 2005 and March 2016 was retrieved from search results using the terms ‘domestic violence’ or ‘intimate partner violence’ in different combinations with other relevant terms, resulting in 1671 documents, of which 59 were systematic reviews. Electronic databases (Medline (Ovid), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Psycinfo, Social work Abstracts, Informit, Violence and Abuse Abstracts, Family Studies Abstracts, Cochrane Library of Systematic Reviews and EMBASE) were searched and narrative analysis undertaken. Results This review details the evidence base for the following interventions by health services responding to domestic violence: first-line responses, routine screening, risk assessment and safety planning, counselling with women, mother–child interventions, responses to perpetrators, child protection notifications, training and system-level responses. Conclusions There is growing evidence for the effectiveness of health service interventions to reduce the extent of harm caused by domestic violence. What is known about the topic? Domestic violence is a significant problem globally with enormous human, social and economic costs. Although women who have experienced abuse make extensive use of healthcare services, health services have lagged behind the policing, criminal justice and other human service domains in responding to domestic violence. What does this paper add? The present comprehensive review identifies best-practice health system responses to domestic violence. What are the implications for practitioners? Health systems can play a key role in identifying and responding to domestic violence for women who often do not access other services. There is growing evidence for the effectiveness of health service interventions to reduce the extent of harm caused by domestic violence, in particular for specialist counselling, structured risk assessment and safety planning, training for first-line responses and interventions for mothers and children affected by domestic violence.

A scoping review of intimate partner violence assistance programmes within health care settings

Background: The lifetime prevalence of intimate partner violence (IPV) for women presenting to health care settings is estimated to be 38-59%. With the goal of providing help to victims of abuse, numerous IPV assistance programmes have been developed and evaluated across multiple health care settings. Objective: Our scoping review provides an overview of this literature to identify key areas for potential evidence-based recommendations and to focus research priorities. Methods: We conducted a search of MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and psycINFO. We used broad eligibility criteria to identify studies that evaluated the effectiveness of IPV assistance programmes delivered within health care settings. We completed all screening and data extraction independently and in duplicate. We used descriptive statistics to summarize all data. Results: Forty-three studies met all eligibility criteria and were included in our scoping review. Nine categories of assistance programmes were identified: counselling/advocacy, safety assessment/planning, referral, providing IPV resources, home visitation, case management, videos, provider cueing, and system changes. Characteristics of programmes amongst studies frequently reporting positive results included those in which one type of active assistance was used (77.8% of studies reported positive results), a counsellor, community worker, or case manager provided the intervention (83.3% of studies reported positive results), and programmes that were delivered over more than five sessions (100.0% of studies reported positive results). Conclusions: IPV assistance programmes are heterogeneous with regards to the types of assistance they include and how they are delivered and evaluated. This heterogeneity creates challenges in identifying which IPV assistance programmes, and which aspects of these programmes, are effective. However, it appears that many different types of IPV assistance programmes can have positive impacts on women.

Testing a counselling intervention in antenatal care for women experiencing partner violence: a study protocol for a randomized controlled trial in Johannesburg, South Africa

BACKGROUND

Intimate partner violence (IPV) during or before pregnancy is associated with many adverse health outcomes. Pregnancy-related complications or poor infant health outcomes can arise from direct trauma as well as physiological effects of stress, both of which impact maternal health and fetal growth and development. Antenatal care can be a key entry point within the health system for many women, particularly in low-resource settings. Interventions to identify violence during pregnancy and offer women support and counselling may reduce the occurrence of violence and mitigate its consequences.

METHODS

Following a formative research phase, a randomized controlled trial will be conducted to test a nurse-led empowerment counselling intervention, originally developed for high-income settings and adapted for urban South Africa. The primary outcome is reduction of partner violence, and secondary outcomes include improvement in women's mental health, safety and self-efficacy. The study aims to recruit 504 pregnant women from three antenatal clinics in Johannesburg who will be randomized to the nurse-led empowerment arm (two 30-min counselling sessions) or enhanced control condition (a referral list) to determine whether participants in the intervention arm have better outcomes as compared to the those in the control arm.

DISCUSSION

This research will provide much needed evidence on whether a short counselling intervention delivered by nurses is efficacious and feasible in low resource settings that have high prevalence of IPV and HIV.

TRIAL REGISTRATION

The study was registered in the South African Clinical Trials Registry (DOH-27-0414-4720) on 11 August 2014 and in the ISRCTN Registry ( ISRCTN35969343 ) on 23 May 2016).

Interventions to support recovery after domestic and sexual violence in primary care

Experiences of domestic and sexual violence are common in patients attending primary care. Most often they are not identified due to barriers to asking by health practitioners and disclosure by patients. Women are more likely than men to experience such violence and present with mental and physical health symptoms to health practitioners. If identified through screening or case finding as experiencing violence they need to be supported to recover from these traumas. This paper draws on systematic reviews published in 2013-2015 and a further literature search undertaken to identify recent intervention studies relevant to recovery from domestic and sexual violence in primary care. There is limited evidence as to what interventions in primary care assist with recovery from domestic violence; however, they can be categorized into the following areas: first line response and referral, psychological treatments, safety planning and advocacy, including through home visitation and peer support programmes, and parenting and mother-child interventions. Sexual violence interventions usually include trauma informed care and models to support recovery. The most promising results have been from nurse home visiting advocacy programmes, mother-child psychotherapeutic interventions, and specific psychological treatments (Cognitive Behaviour Therapy, Trauma informed Cognitive Behaviour Therapy and, for sexual assault, Exposure and Eye Movement Desensitization and Reprocessing Interventions). Holistic healing models have not been formally tested by randomized controlled trials, but show some promise. Further research into what supports women and their children on their trajectory of recovery from domestic and sexual violence is urgently needed.

Improving mental health service responses to domestic violence and abuse

Domestic violence and abuse is a considerable international public health problem, which is associated with mental disorders in both women and men. Nevertheless, victimization and perpetration remain undetected by mental health services. This paper reviews the evidence on mental health service responses to domestic violence, including identifying, referring, and providing care for people experiencing or perpetrating violence. The review highlights the need for mental health services to improve rates of identification and responses to domestic violence and abuse, through the provision of specific training on domestic violence and abuse, the implementation of clear information sharing protocols and evidence-based interventions, and the establishment of care referral pathways. This review also highlights the need for further research into mental health service users who perpetrate domestic violence and abuse.

Surveillance for Violent Deaths - National Violent Death Reporting System, 17 States, 2013

PROBLEM/CONDITION

In 2013, more than 57,000 persons died in the United States as a result of violence-related injuries. This report summarizes data from CDC's National Violent Death Reporting System (NVDRS) regarding violent deaths from 17 U.S. states for 2013. Results are reported by sex, age group, race/ethnicity, marital status, location of injury, method of injury, circumstances of injury, and other selected characteristics.

REPORTING PERIOD COVERED

2013.

DESCRIPTION OF SYSTEM

NVDRS collects data from participating states regarding violent deaths obtained from death certificates, coroner/medical examiner reports, law enforcement reports, and secondary sources (e.g., child fatality review team data, supplemental homicide reports, hospital data, and crime laboratory data). This report includes data from 17 states that collected statewide data for 2013 (Alaska, Colorado, Georgia, Kentucky, Maryland, Massachusetts, North Carolina, New Jersey, New Mexico, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Virginia, and Wisconsin). NVDRS collates documents for each death and links deaths that are related (e.g., multiple homicides, a homicide followed by a suicide, or multiple suicides) from a single incident.

RESULTS

For 2013, a total of 18,765 fatal incidents involving 19,251 deaths were captured by NVDRS in the 17 states included in this report. The majority (66.2%) of deaths were suicides, followed by homicides (23.2%), deaths of undetermined intent (8.8%), deaths involving legal intervention (1.2%) (i.e., deaths caused by law enforcement and other persons with legal authority to use deadly force, excluding legal executions), and unintentional firearm deaths (<1%). (The term legal intervention is a classification incorporated into the International Classification of Diseases, Tenth Revision [ICD-10] and does not denote the lawfulness or legality of the circumstances surrounding a death caused by law enforcement.) Suicides occurred at higher rates among males, non-Hispanic whites, American Indian/Alaska Natives, persons aged 45-64 years, and males aged ≥75 years. Suicides were preceded primarily by a mental health, intimate partner, or physical health problem or a crisis during the previous or upcoming 2 weeks. Homicide rates were higher among males and persons aged 15-44 years; rates were highest among non-Hispanic black males. Homicides primarily were precipitated by arguments and interpersonal conflicts, occurrence in conjunction with another crime, or were related to intimate partner violence (particularly for females). A known relationship between a homicide victim and a suspected perpetrator was most likely either that of an acquaintance or friend or an intimate partner. Legal intervention death rates were highest among males and persons aged 20-24 years and 30-34 years; rates were highest among non-Hispanic black males. Precipitating factors for the majority of legal intervention deaths were another crime, a mental health problem, or a recent crisis. Deaths of undetermined intent occurred at the highest rates among males and persons aged <1 year and 45-54 years. Substance abuse and mental or physical health problems were the most common circumstances preceding deaths of undetermined intent. Unintentional firearm death rates were higher among males, non-Hispanic whites, and persons aged persons aged 15-19 and 55-64 years; these deaths were most often precipitated by a person unintentionally pulling the trigger while playing with a firearm or while hunting.

INTERPRETATION

This report provides a detailed summary of data from NVDRS for 2013. The results indicate that violent deaths resulting from self-inflicted or interpersonal violence disproportionately affected persons aged <65 years, males, and certain minority populations. For homicides and suicides, intimate partner problems, interpersonal conflicts, mental health problems, and recent crises were primary precipitating factors.

PUBLIC HEALTH ACTION

NVDRS data are used to monitor the occurrence of violence-related fatal injuries and assist public health authorities in the development, implementation, and evaluation of programs and policies to reduce and prevent violent deaths. For example, Utah Violent Death Reporting System (VDRS) data were used to develop policies that support children of intimate partner homicide victims, Colorado VDRS data to develop a web-based suicide prevention program targeting middle-aged men, and Rhode Island VDRS data to help guide suicide prevention efforts at workplaces. The continued development and expansion of NVDRS to include all U.S. states, territories, and the District of Columbia are essential to public health efforts to reduce the impact of violence.

Relationship of Physical Intimate Partner Violence with Mental Health Diagnoses in the Nationwide Emergency Department Sample

OBJECTIVES

We examined associations of physical intimate partner violence (PIPV) with selected mental health disorders using a nationally representative sample of emergency department (ED) discharges corresponding to men and women (18-64 years) from the 2010 Nationwide Emergency Department Sample.

METHODS

PIPV was determined using International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) external cause of injury code E967.3 (battering by spouse or partner). ICD-9-CM clinical classification of discharge diagnoses was used to identify mental health disorders. Multivariable logistic regression models were constructed to estimate adjusted odds ratios (OR_adj) and their 95% confidence intervals (CIs).

RESULTS

PIPV prevalence was estimated at 0.36 per 1000 ED discharges. The strongest correlates of PIPV were alcohol-related (OR_adj = 3.02, 95% CI: 2.62-3.50), adjustment (OR_adj = 2.37, 95% CI: 1.56-3.58), intentional self-harm (OR_adj = 1.41, 95% CI: 1.05-1.89), anxiety (OR_adj = 1.23, 95% CI: 1.07-1.40), drug-related (OR_adj = 1.22, 95% CI: 1.01-1.47), and mood (OR_adj = 1.16, 95% CI: 1.04-1.31) disorders. PIPV's association with alcohol-related disorders was stronger among women (OR_adj = 3.22, 95% CI: 2.79-3.72) versus men (OR_adj = 1.98, 95% CI: 1.42-2.77). Similarly, drug-related disorders were stronger correlates of PIPV among women (OR_adj = 1.32, 95% CI: 1.09-1.60) versus men (OR_adj = 0.59, 95% CI: 0.31-1.16).

CONCLUSIONS

In EDs, PIPV was linked to several mental health disorders, with women experiencing comorbid PIPV and substance use more frequently than men.

No Quick Fixes: A Mixed Methods Feasibility Study of an Urban Community Health Worker Outreach Program for Intimate Partner Violence

Community health workers (CHWs) provide peer support in diverse health care settings, but few studies have evaluated CHW interventions for intimate partner violence (IPV). We assessed the feasibility, acceptability, and safety of CHW outreach in four urban community health clinics and characterized the experiences and barriers to providing safe and effective services for women experiencing IPV. CHWs successfully enrolled and engaged IPV victims, who indicated satisfaction and increased safety with program participation. However, complex psychosocial barriers prevented many from achieving safety and security. More work is needed to assess the impact of well-integrated IPV-trained CHWs in primary care medical homes.

Intimate partner violence screening and counseling in the health care setting: Perception of provider-based discussions as a strategic response to IPV

Intimate partner violence (IPV) affects women worldwide, and is addressable in the health care setting not only via screening, but also through provider-based counseling and referral to legal or social services, as appropriate. We conducted a study in Pennsylvania (USA) examining factors associated with receipt of IPV screening and women's perceptions of counseling discussions as a strategic response. We found that women with past-year IPV were more likely to receive screening (aOR: 2.0, 95%CI: 1.2,3.5) and to consider counseling discussions to be a strategic response to IPV exposure (aOR: 2.7, 95%CI: 1.008,7.2) than women with a more distant history of IPV. Scholars and clinicians may learn that, especially for women with a recent history of IPV, screening may provide a conduit to meaningful counseling discussions and referrals that women view as a helpful strategy in responding to IPV.

Sexual and physical abuse and gynecologic disorders

STUDY QUESTION

Is sexual and/or physical abuse history associated with incident endometriosis diagnosis or other gynecologic disorders among premenopausal women undergoing diagnostic and/or therapeutic laparoscopy or laparotomy regardless of clinical indication?

SUMMARY ANSWER

No association was observed between either a history of sexual or physical abuse and risk of endometriosis, ovarian cysts or fibroids; however, a history of physical abuse was associated with a higher likelihood of adhesions after taking into account important confounding and mediating factors.

WHAT IS KNOWN ALREADY

Sexual and physical abuse may alter neuroendocrine-immune processes leading to a higher risk for endometriosis and other noninfectious gynecologic disorders, but few studies have assessed abuse history prior to diagnosis.

STUDY DESIGN, SIZE, DURATION

The study population for these analyses includes the ENDO Study (2007-2009) operative cohort: 473 women, ages 18-44 years, who underwent a diagnostic and/or therapeutic laparoscopy or laparotomy at 1 of the 14 surgical centers located in Salt Lake City, UT, USA or San Francisco, CA, USA. Women with a history of surgically confirmed endometriosis were excluded.

PARTICIPANTS/MATERIALS, SETTING AND METHODS

Prior to surgery, women completed standardized abuse questionnaires. Relative risk (RR) of incident endometriosis, uterine fibroids, adhesions or ovarian cysts by abuse history were estimated, adjusting for age, race/ethnicity, education, marital status, smoking, gravidity and recruitment site. We assessed whether a history of chronic pelvic pain, depression, or STIs explained any relationships via mediation analyses.

MAIN RESULTS AND ROLE OF CHANCE

43 and 39% of women reported experiencing sexual and physical abuse. No association was observed between either a history of sexual or physical abuse, versus no history, and risk of endometriosis (aRR: 1.00 [95% confidence interval (CI): 0.80-1.25]); aRR: 0.83 [95% CI: 0.65-1.06]), ovarian cysts (aRR: 0.67 [95% CI: 0.39-1.15]); aRR: 0.60 [95% CI: 0.34-1.09]) or fibroids (aRR: 1.25 [95% CI: 0.85-1.83]); aRR: 1.36 [95% CI: 0.92-2.01]). Conversely, a history of physical abuse, versus no history, was associated with higher risk of adhesions (aRR: 2.39 [95% CI: 1.18-4.85]). We found no indication that the effect of abuse on women's adhesion risk could be explained by a history of chronic pelvic pain, depression or STIs.

LIMITATIONS, REASONS FOR CAUTION

Limitations to our study include inquiries on childhood physical but not sexual abuse. Additionally, we did not inquire about childhood or adulthood emotional support systems, found to buffer the negative impact of stress on gynecologic health.

WIDER IMPLICATIONS OF THE FINDINGS

Abuse may be associated with some but not all gynecologic disorders with neuroendocrine-inflammatory origin. High prevalence of abuse reporting supports the need for care providers to screen for abuse and initiate appropriate follow-up.

STUDY FUNDING/COMPETING INTERESTS

Supported by the Intramural Research Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development (contracts NO1-DK-6-3428, NO1-DK-6-3427, and 10001406-02). The authors have no potential competing interests.

Domestic Violence Enhanced Perinatal Home Visits: The DOVE Randomized Clinical Trial

BACKGROUND

Perinatal intimate partner violence (IPV) is common and has significant negative health outcomes for mothers and infants. This study evaluated the effectiveness of an IPV intervention in reducing violence among abused women in perinatal home visiting programs.

MATERIALS AND METHODS

This assessor-blinded multisite randomized control trial of 239 women experiencing perinatal IPV was conducted from 2006 to 2012 in U.S. urban and rural settings. The Domestic Violence Enhanced Home Visitation Program (DOVE) intervention group (n = 124) received a structured abuse assessment and six home visitor-delivered empowerment sessions integrated into home visits. All participants were screened for IPV and referred appropriately. IPV was measured by the Conflicts Tactics Scale2 at baseline through 24 months postpartum.

RESULTS

There was a significant decrease in IPV over time (F = 114.23; p < 0.001) from baseline to 1, 3, 6, 12, 18, and 24 months postpartum (all p < 0.001). Additional models examining change in IPV from baseline indicated a significant treatment effect (F = 6.45; p < 0.01). Women in the DOVE treatment group reported a larger mean decrease in IPV scores from baseline compared to women in the usual care group (mean decline 40.82 vs. 35.87). All models accounted for age and maternal depression as covariates.

CONCLUSIONS

The DOVE intervention was effective in decreasing IPV and is brief, thereby facilitating its incorporation within well-woman and well-child care visits, as well as home visiting programs, while satisfying recommendations set forth in the Affordable Care Act for IPV screening and brief counseling.

Receiving care for intimate partner violence in primary care: Barriers and enablers for women participating in the weave randomised controlled trial

BACKGROUND

Interventions in health settings for intimate partner violence (IPV) are being increasingly recognised as part of a response to addressing this global public health problem. However, interventions targeting this sensitive social phenomenon are complex and highly susceptible to context. This study aimed to elucidate factors involved in women's uptake of a counselling intervention delivered by family doctors in the weave primary care trial (Victoria, Australia).

METHODS

We analysed associations between women's and doctors' baseline characteristics and uptake of the intervention. We interviewed a random selection of 20 women from an intervention group women to explore cognitions relating to intervention uptake. Interviews were audio-recorded, transcribed, coded in NVivo 10 and analysed using the theory of planned behaviour (TPB).

RESULTS

Abuse severity and socio-demographic characteristics (apart from current relationship status) were unrelated to uptake of counselling (67/137 attended sessions). Favourable doctor communication was strongly associated with attendance. Eight themes emerged, including four sets of beliefs that influenced attitudes to uptake: (i) awareness of the abuse and readiness for help; (ii) weave as an avenue to help; (iii) doctor's communication; and (iv) role in providing care for IPV; and four sets of beliefs regarding women's control over uptake: (v) emotional health, (vi) doctors' time, (vii) managing the disclosure process and (viii) viewing primary care as a safe option.

CONCLUSIONS

This study has identified factors that can promote the implementation and evaluation of primary care-based IPV interventions, which are relevant across health research settings, for example, ensuring fit between implementation strategies and characteristics of the target group (such as range in readiness for intervention). On practice implications, providers' communication remains a key issue for engaging women. A key message arising from this work concerns the critical role of primary care and health services more broadly in reaching victims of domestic violence, and providing immediate and ongoing support (depending on the healthcare context).

Reproductive Health Knowledge among African American Women Enrolled in a Clinic-Based Randomized Controlled Trial to Reduce Psychosocial and Behavioral Risk: Project DC-HOPE

BACKGROUND

Washington, DC, has among the highest rates of sexually transmitted infections and unintended pregnancy in the United States. Increasing women's reproductive health knowledge may help to address these reproductive health issues. This analysis assessed whether high-risk pregnant African American women in Washington, DC, who participated in an intervention to reduce behavioral and psychosocial risks had greater reproductive health knowledge than women receiving usual care.

METHODS

Project DC-HOPE was a randomized, controlled trial that included pregnant African American women in Washington, DC, recruited during prenatal care (PNC). Women in the intervention group were provided reproductive health education and received tailored counseling sessions to address their psychosocial and behavioral risk(s) (cigarette smoking, environmental tobacco smoke exposure, depression, and intimate partner violence). Women in the control group received usual PNC. Participants completed a 10-item reproductive knowledge assessment at baseline (n = 1,044) and postpartum (n = 830). Differences in total reproductive health knowledge scores at baseline and postpartum between groups were examined via χ(2) tests. Differences in postpartum mean total score by group were assessed via multiple linear regression.

RESULTS

Women in both groups and at both time points scored approximately 50% on the knowledge assessments. At postpartum, women in the intervention group had higher total scores compared with women receiving usual care (mean 5.40 [SD 1.60] vs. 5.03 [SD 1.53] out of 10, respectively; p < .001).

CONCLUSIONS

Although intervention participants increased reproductive health knowledge, overall scores remained low. Development of interventions designed to impart accurate, individually tailored information to women may promote reproductive health knowledge among high-risk pregnant African American women residing in Washington, DC.