Health indicators and intimate partner violence among women who are members of a managed care organization

Prognostic factors of first intimate partner violence among ever-married women in Sub-Saharan Africa: Gompertz gamma shared frailty modeling

BACKGROUND

Violence against women, particularly intimate partner violence, is a significant Concern for public health as well as a violation of the human rights of women especially in low and middle-income countries. However, there was limited evidence how soon an ever-married women experience intimate partner violence in Africa. Therefore, this study aimed to investigate the timing of first intimate partner violence (FIPV) among ever-married women in 30 SSA countries and to identify the risk factors of the timing.

METHODS

The present study has utilized 125,731 weighted samples, who participated in the domestic violence module of the survey from Demographic and Health Surveys of 30 SSA countries. The Gompertz gamma shared frailty model was fitted to determine the predictors. For model evaluation, the theta value, Akaike Information Criteria (AIC), Bayesian Information Criteria (BIC), and deviance were used. The Adjusted Hazard Ratio (AHR) with a 95% Confidence Interval (CI) was reported in the multivariable Gompertz gamma shared frailty model to highlight the strength and statistical significance of the associations.

RESULT

One-third (31.02%) of ever-married women had reported experiencing IPV. The overall incidence rate of FIPV was 57.68 persons per 1000 person-years (95% CI = 50.61-65.76). Age at marriage, age difference, educational status, employment, residence, women's decision-making autonomy, husband who drink alcohol and wealth status were significantly associated with the timing of FIPV.

CONCLUSION

The findings show that ever-married women are at high and increasing risk of violence. Thus, we recommend establishing effective health and legal response services for IPV, strengthening laws governing the sale and purchase of alcohol, empowering women, raising the educational attainment of women, and putting policies in place to combat the culture of societal tolerance for IPV all contribute to the empowerment of women.

Physician Assistants' Training and Self-Perceived Competencies to Work with Survivors of Intimate Partner Violence

INTRODUCTION

The purpose of this research was to assess physician assistant (PA) education and training on the diagnosis, management, and treatment of survivors of intimate partner violence (IPV), as well as perceived current vs. desired skills in tasks related to the management and treatment of IPV.

METHODS

Participants in 2 studies included a convenience sample of attendees at an annual PA conference (study 1) and PAs in the United States who were randomly selected to be administered an online survey related to their PA practice (study 2).

RESULTS

In 2 studies, PAs reported low perceived competence to treat and manage patients who are survivors of IPV. More than half of the respondents (51.2%) had received training to work with survivors of IPV. Almost 3 in 5 indicated that they felt adequately prepared, and almost 3 in 10 regularly asked patients about IPV. Gaps between current and desired perceived skills to treat and manage survivors of IPV were larger among PAs who had previous training related to IPV compared with PAs with no prior training.

DISCUSSION

Guidance for PA educators may improve PA education and increase competencies among new PAs. Without more substantial guidance from an accrediting body, PA programs are left responsible for implementing IPV curriculum. Professional associations as well as constituent and specialty organizations that provide continuing medical education have an equally important role in strengthening skills and abilities among PAs.

A Novel Technique to Identify Intimate Partner Violence in a Hospital Setting

Introduction

Intimate partner violence (IPV) is defined as sexual, physical, psychological, or economic violence that occurs between current or former intimate partners. Victims of IPV may seek care for violence-related injuries in healthcare settings, which makes recognition and intervention in these facilities critical. In this study our goal was to develop an algorithm using natural language processing (NLP) to identify cases of IPV within emergency department (ED) settings.

Methods

In this observational cohort study, we extracted unstructured physician and advanced practice provider, nursing, and social worker notes from hospital electronic health records (EHR). The recorded clinical notes and patient narratives were screened for a set of 23 situational terms, derived from the literature on IPV (ie, assault by spouse), along with an additional set of 49 extended situational terms, extracted from known IPV cases (ie, attack by spouse). We compared the effectiveness of the proposed model with detection of IPV-related International Classification of Diseases, 10th Revision, codes.

Results

We included in the analysis a total of 1,064,735 patient encounters (405,303 patients who visited the ED of a Level I trauma center) from January 2012–August 2020. The outcome was identification of an IPV-related encounter. In this study we used information embedded in unstructured EHR data to develop a NLP algorithm that employs clinical notes to identify IPV visits to the ED. Using a set of 23 situational terms along with 49 extended situational terms, the algorithm successfully identified 7,399 IPV-related encounters representing 5,975 patients; the algorithm achieved 99.5% precision in detecting positive cases in our sample of 1,064,735 ED encounters.

Conclusion

Using a set of pre-defined IPV-related terms, we successfully developed a novel natural language processing algorithm capable of identifying intimate partner violence.

"I forgive myself": The association between self-criticism, self-acceptance, and PTSD in women victims of IPV, and the buffering role of self-efficacy

The effects of intimate partner violence (IPV) concerning specifically posttraumatic stress disorder (PTSD) symptomatology have been widely demonstrated, but the consequences of abuse are not the same for all victims. We know little about the psychological processes that limit these adverse consequences. Therefore, we explored the association between self-criticism felt by abused women and their PTSD, and we investigated self-acceptance as the underlying process explaining this relationship. We also examined self-efficacy as the protective (moderating) factor. The results indicated that self-criticism was indirectly associated with greater PTSD via lower self-acceptance. Critically, the indirect effect only emerged for individuals low in self-efficacy.

Ethnoregional Dynamics of Intimate Partner Violence Against Women in Nigeria

Intimate partner violence (IPV) is a reality the average Nigerian woman has to grapple with everyday. Ethnicity and place of residence play a pivotal role in the social realities of Nigerian women, especially with their experience of IPV. However, there is a paucity of reviews examining the impact of ethnicity and place of residence on women's experiences of IPV in Nigeria. This study seeks to explore the ethnoregional dynamics of IPV from the range of studies undertaken on the subject matter. Eighteen studies meant the inclusion criteria for analysis. The major criteria for selecting studies for analysis were peer-reviewed studies on IPV against women and studies on a Nigerian population, regardless of the nationality of the authors. Databases like the University of Saskatchewan Library, ProQuest, Sociological Abstracts, and Journal Storage (JSTOR) were used in searching for peer-reviewed studies. The study revealed that Igbo women tend to experience IPV more than Yoruba and Hausa women. The study also found that rural women tend to experience IPV more than urban women. The study points out some of the services available for female victims of IPV and the possible strategies that can be adapted to reach them effectively.

Partner Abuse Among Treatment-Seeking Individuals with Chronic Pain: Prevalence, Characteristics, and Association with Pain-Related Outcomes

OBJECTIVE

This study assessed the prevalence of abusive partner relationships among individuals presenting for chronic pain treatment. In addition, this study examined the association between partner abuse histories and pain-relevant outcome variables.

DESIGN

Cross-sectional.

SETTING

This study took place at a specialty pain rehabilitation treatment center in the Midwestern United States.

SUBJECTS

Participants in this study (N = 108) included adults (Mage = 45.73 [15.95] years) presenting for chronic pain treatment who consented to participate in a research study on stress, relationships, and chronic pain.

METHODS

Participants completed self-report measures about relationship and abuse histories, physical and mental health, and demographic information. Participants were categorized into the following groups: no intimate partner violence (IPV), past IPV (>12 months ago), or current/recent IPV (≤12 months ago).

RESULTS

Results indicated that over half (56%) of the sample endorsed a history of partner abuse and around one-third (29%) of the sample had experienced abuse within the past year. Psychological/emotional abuse was the most common form of abuse reported. Those with current/recent abuse histories reported greater impairment in pain interference, post-traumatic stress symptoms, mental health functioning, and pain self-efficacy compared with those who had not experienced abuse in the past year.

CONCLUSIONS

Partner abuse appears common among individuals with chronic pain and is associated with pain-relevant outcomes, warranting additional clinical attention and research in this area.

The association between intimate partner violence, psychiatric morbidity amongst pregnant women and partner alcohol use in southern Nigeria

BACKGROUND

Intimate partner violence (IPV) against women is common, although prevalence and correlates amongst pregnant women in developing countries are poorly researched.

AIM

To identify the magnitude of IPV, and its relationship with psychiatric morbidity and partner alcohol use.

SETTING

This study was conducted among women receiving routine ante-natal care at a secondary level healthcare facility in southern Nigeria.

METHODS

A cross-sectional descriptive study was conducted by recruiting pregnant women (n = 395) attending the Ante-Natal Clinic of the Central Hospital, Benin-City, Edo State, Nigeria, between August 2015 and February 2016 and undertaking face-to-face interviews utilising a socio-demographic questionnaire, the Composite Abuse Scale and the 20-item Self-reporting Questionnaire.

RESULTS

Past 12-month prevalence of IPV was 24.8%, with emotional abuse being the commonest type (89.8%). Forty-six participants (11.6%) screened positive for probable psychiatric morbidity. Predictors of IPV included partner alcohol use in the past 12 months (adjusted odds ratio [aOR]: 2.67; 95% confidence interval [CI]: 1.16-6.16; p 0.02), having a psychiatric morbidity (aOR: 2.53; 95% CI: 1.27-5.04; p 0.01), being single (aOR: 2.12; 95% CI: 1.25-3.58; p 0.01) and multiparous (aOR: 2.5; 95% CI: 1.43-4.38; p 0.001).

CONCLUSION

Intimate partner violence was common amongst pregnant women in Nigeria. Identified modifiable risk factors can be targets for screening and intervention for women in these settings.

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

Background

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

Methods

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

Results

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

Conclusions

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

Risk and Protective Factors Associated With Intimate Partner Violence in a Nationally Representative Sample of Korean Men

OBJECTIVES

In recent years, multiple studies have investigated the issue of intimate partner violence (IPV) in Korea. However, most of those studies have focused on IPV against women, while overlooking the problem of men IPV victimization. Considering this, the current study identified risk and protective factors for IPV and examined their influence on IPV victimization among Korean men.

METHODS

We used a nationally representative sample of 1668 Korean men from the 2013 Korea National Survey on Domestic Violence. The associations between potential IPV risk factors and different types of IPV were investigated using univariate and multivariate logistic regression. Specifically, separate analyses were conducted of 5 types of IPV (neglect, controlling behaviors, emotional violence, economic violence, and physical violence).

RESULTS

The prevalence of IPV among Korean men and women showed only marginal gender differences. Controlling behaviors (men, 23.3%; women, 23.9%) and emotional violence (men, 16.5%; women, 18.8%) were the most common types of IPV reported, followed by neglect (men, 11.2%; women, 11.7%). Separate logistic regression analyses for the 5 subtypes of IPV revealed that mutual IPV was a strong predictor of IPV. Men who abused their wives were more likely to experience neglect (odds ratio [OR], 29.24; p<0.01), controlling behaviors (OR, 36.61; p<0.01), emotional violence (OR, 58.07; p<0.01), economic violence (OR, 18.78; p<0.01), and physical violence (OR, 38.09; p<0.01).

CONCLUSIONS

The findings of this study suggest that IPV intervention strategies should particularly focus on couples whose relationship is characterized by patterns of bidirectional violence.

A randomized pilot trial of two parenting interventions for fathers in residential substance use disorder treatment

Residential substance misuse treatment programs for men typically do not integrate treatment for intimate partner violence (IPV) or parenting despite significant overlap between substance misuse, IPV and child maltreatment. A randomized trial compared two fatherhood focused interventions in 6-month residential substance misuse treatment programs. Fathers for Change (F4C) is an integrated intervention targeting IPV and child maltreatment. Dads 'n' Kids (DNK) is a psychoeducational intervention focused on child development and behavioral parenting skills. Sixty-two fathers were randomly assigned to F4C or DNK. They received 12 weeks of individual treatment while in the residential facility and were offered 4 aftercare sessions following discharge. They were assessed prior to treatment, at the time of residential discharge, following completion of the intervention booster sessions, and 3 months following intervention. Overall, both groups showed significant reductions in affect dysregulation, anger, and IPV. F4C fathers showed significantly greater decreases in affect dysregulation problems. There were no significant differences between groups on IPV but men who received F4C may have been less likely to use substances after leaving residential treatment. Integration of fatherhood focused interventions were possible and welcomed by residents at the facilities. F4C showed some benefit over DNK in terms of affect dysregulation symptoms and substance use relapse.

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

OBJECTIVES

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

DESIGN AND SETTING

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

PARTICIPANTS

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

INTERVENTIONS

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

RESULTS

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

CONCLUSION

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

Detection of domestic violence by community mental health teams: a multi-center, cluster randomized controlled trial

BACKGROUND

Domestic Violence and Abuse (DVA) is associated with a range of psychosocial and mental health problems. Having a psychiatric illness increases likelihood of being a victim of DVA. Despite the evidence of a high risk for DVA and the serious effects of violent victimization in psychiatric patients, detection rates are low and responses are inadequate. The aim of the BRAVE (Better Reduction trough Assessment of Violence and Evaluation) study is to improve detection of and response to DVA in psychiatric patients. In this article, we present the protocol of the BRAVE study which follows the SPIRIT guidelines.

METHODS

The BRAVE study is a cluster randomized controlled trial. We will include 24 community mental health teams from Rotterdam and The Hague. Twelve teams will provide care as usual and 12 teams will receive the intervention. The intervention consists of 1) a knowledge and skills training for mental health professionals about DVA, 2) a knowledge and skills training of DVA professionals about mental illness, 3) provision and implementation of a referral pathway between community mental health and DVA services. The follow up period is 12 months. Our primary outcome is the rate of detected cases of recent or any history of DVA in patients per team in 12 months. Detection rates are obtained through a systematic search in electronic patient files. Our secondary aims are to obtain information about the gain and sustainability of knowledge on DVA in mental health professionals, and to obtain insight into the feasibility, sustainability and acceptability of the intervention. Data on our secondary aims will be obtained through structured in depth interviews and a questionnaire on knowledge and attitudes on DVA.

DISCUSSION

This study is the first cluster randomized controlled trial to target both male and female psychiatric patients that experience DVA, using an intervention that involves training of professionals. We expect the rate of detected cases of DVA to increase in the intervention teams. With early detection of victimization of DVA in psychiatric patients we hope to improve the mental health of psychiatric patients in the short and long term.

TRIAL REGISTRATION

ISRCTN:14115257 . Date of registration: 15th January 2015.

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

OBJECTIVES

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

DESIGN

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

SETTING

Community-based, across the UK.

PARTICIPANTS

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

RESULTS

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

CONCLUSIONS

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

Military/Civilian Risk Markers for Physical Intimate Partner Violence: A Meta-Analysis

This meta-analysis compared risk markers for perpetration of physical intimate partner violence (IPV) among military and civilian males. We also examined strength of risk markers among male and female service members. In total, 36 military studies and 334 civilian studies, which reported 883 effect sizes, were included in the analyses. Results revealed more similarities than differences in risk markers for IPV among military and civilian males and among military males and females. Of the risk markers examined, relationship satisfaction and alcohol problems were significantly stronger risk markers for IPV among civilian males compared to military males. Perpetrating emotional abuse was a significantly stronger risk marker for IPV perpetration among military females compared to military males. Recommendations for IPV prevention and intervention are discussed.

Racial Disparities in Intimate Partner Violence Examined Through the Multiple Disadvantage Model

This research adopted the perspective of the multiple disadvantage model to explore racial disparities in intimate partner violence (IPV) against women and IPV's links to social structural factors, social relationships, substance use, and health/mental health and access to related services. The study used data from 6,588 women who completed the National Violence Against Women Survey; linear regression was conducted separately for four ethnic groups. Results consistently showed physical assaults to increase with posttraumatic stress disorder symptoms. For African Americans, increases in assaults were linked to injury, disclosing IPV to friends/family as well as medical professionals, Medicaid use, and drug use; decreases, in turn, were linked to past assault by ex-partners. For Latinas, increases in assaults were associated with eight factors: being married, number of ex-partners, depression, disclosing IPV to friends/family and disclosing to mental-health professionals, drug use, alcohol abstinence, and partner's frequent alcohol use. For European Americans, increases in assaults were linked to number of ex-partners, injury, low income, Medicaid use, disclosing IPV to friends/family as well as mental-health professionals, and alcohol abstinence; decreases were associated with age and with other health insurance coverages. For women of other ethnicity, increases were linked to number of ex-partners, disclosing IPV to mental-health professionals, Medicaid use, drug use, and woman's own as well as partner's alcohol abstinence; decreases in this ethnicity category were linked to past assault by ex-partners. Intervention and policy implications are discussed.

The Impact of Family and Friends’ Reactions on the Well-Being of Women With Abusive Partners

This study examined the degree to which battered women talked with family and friends about abuse they were experiencing and how family and friends responded. Participants were 137 women who had recently experienced domestic violence and were exiting a shelter. Most women confided in family and friends about the abuse. Family and friends’ reactions depended on contextual factors, including the woman’s relationship with her assailant, number of separations, number of children, and whether family and friends were threatened. Family and friends’ negative reactions and offers of tangible support were significantly related to women’s well-being, although positive emotional support was not.

African American HMO Enrollees

Intimate partner violence has been demonstrated to be a significant public health problem among African American women. This study provided an opportunity to examine prevalence of intimate partner violence and health consequences among a group of primarily middle-class, employed African American women enrolled in a privately insured HMO (n = 109 abused and 97 never-abused women). Significantly more abused African American women were divorced or widowed and had incomes less than $50,000 a year. Abused women had more health problems (central nervous system, gynecological, STDs, gastrointestinal), more health problems per medical visits, and more emergency room visits (p < .05) compared to never-abused women. The health consequences of abuse and its association with health disparities are discussed.

Effects of Intimate Partner Violence Versus Poverty on Women's Health

This article investigated whether women's physical health symptoms were due to abuse, poverty, or both. A community sample of 397 women, about half of whom had been assaulted by an intimate partner, were interviewed about their income, experience of physical abuse, and physical health. Hierarchical multiple regression revealed that both income and physical abuse contributed to women's rates of physical health symptoms. Abuse contributed to the variance in physical health beyond that predicted by income level alone. Findings suggest that abuse by an intimate partner or ex-partner negatively affects women's health and is especially detrimental to the health of low-income women.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Intimate Partner Violence Among Hong Kong Young Adults: Prevalence, Risk Factors, and Associated Health Problems

Intimate partner violence is a serious social problem and public health issue affecting the well-being of the young adults. However, there is very little epidemiological evidence on the incidence and associated health problems in contemporary Chinese society. Using a representative community sample of 1,223 young adults aged 18 to 27 years conducted by Hong Kong Family Planning Association in 2011, this study aimed to estimate the prevalence, risk factors, and possible health consequences of intimate partner violence among young adults in Hong Kong. It is found that the prevalence of lifetime and preceding 1-year intimate partner violence by former or current partners was 8.6% and 4.9% respectively. Male youths who were older were less likely to experience past-year intimate partner violence (odds ratio [OR] = 0.21, p < .05) and those who had a university degree or were unemployed were more likely to experience past-year intimate partner violence (OR = 8.48, p < .01 and OR = 8.14, p < .05 respectively). Female youths who had a full-time job were less likely to experience the lifetime violence (OR = 0.15, p < .05) and those who were ever pregnant with current partner were more likely to experience both lifetime intimate partner violence (OR = 5.00, p < .05) and past-year violence (OR = 5.63, p < .05). Both female and male victims were more likely to be subjected to mental health problems and only female victims felt fear for the violent partner.

Screening women for intimate partner violence in healthcare settings

BACKGROUND

Intimate partner violence (IPV) damages individuals, their children, communities, and the wider economic and social fabric of society. Some governments and professional organisations recommend screening all women for IPV rather than asking only women with symptoms (case-finding). Here, we examine the evidence for whether screening benefits women and has no deleterious effects.

OBJECTIVES

To assess the effectiveness of screening for IPV conducted within healthcare settings on identification, referral, re-exposure to violence, and health outcomes for women, and to determine if screening causes any harm.

SEARCH METHODS

On 17 February 2015, we searched CENTRAL, Ovid MEDLINE, Embase, CINAHL, six other databases, and two trial registers. We also searched the reference lists of included articles and the websites of relevant organisations.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials assessing the effectiveness of IPV screening where healthcare professionals either directly screened women face-to-face or were informed of the results of screening questionnaires, as compared with usual care (which could include screening that did not involve a healthcare professional).

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the risk of bias in the trials and undertook data extraction. For binary outcomes, we calculated a standardised estimation of the odds ratio (OR). For continuous data, either a mean difference (MD) or standardised mean difference (SMD) was calculated. All are presented with a 95% confidence interval (CI).

MAIN RESULTS

We included 13 trials that recruited 14,959 women from diverse healthcare settings (antenatal clinics, women's health clinics, emergency departments, primary care) predominantly located in high-income countries and urban settings. The majority of studies minimised selection bias; performance bias was the greatest threat to validity. The overall quality of the body of evidence was low to moderate, mainly due to heterogeneity, risk of bias, and imprecision.We excluded five of 13 studies from the primary analysis as they either did not report identification data, or the way in which they did was not consistent with clinical identification by healthcare providers. In the remaining eight studies (n = 10,074), screening increased clinical identification of victims/survivors (OR 2.95, 95% CI 1.79 to 4.87, moderate quality evidence).Subgroup analyses suggested increases in identification in antenatal care (OR 4.53, 95% CI 1.82 to 11.27, two studies, n = 663, moderate quality evidence); maternal health services (OR 2.36, 95% CI 1.14 to 4.87, one study, n = 829, moderate quality evidence); and emergency departments (OR 2.72, 95% CI 1.03 to 7.19, three studies, n = 2608, moderate quality evidence); but not in hospital-based primary care (OR 1.53, 95% CI 0.79 to 2.94, one study, n = 293, moderate quality evidence).Only two studies (n = 1298) measured referrals to domestic violence support services following clinical identification. We detected no evidence of an effect on referrals (OR 2.24, 95% CI 0.64 to 7.86, low quality evidence).Four of 13 studies (n = 2765) investigated prevalence (excluded from main analysis as rates were not clinically recorded); detection of IPV did not differ between face-to-face screening and computer/written-based assessment (OR 1.12, 95% CI 0.53 to 2.36, moderate quality evidence).Only two studies measured women's experience of violence (three to 18 months after screening) and found no evidence that screening decreased IPV.Only one study reported on women's health with no differences observable at 18 months.Although no study reported adverse effects from screening interventions, harm outcomes were only measured immediately afterwards and only one study reported outcomes at three months.There was insufficient evidence on which to judge whether screening increases uptake of specialist services, and no studies included an economic evaluation.

AUTHORS' CONCLUSIONS

The evidence shows that screening increases the identification of women experiencing IPV in healthcare settings. Overall, however, rates were low relative to best estimates of prevalence of IPV in women seeking healthcare. Pregnant women in antenatal settings may be more likely to disclose IPV when screened, however, rigorous research is needed to confirm this. There was no evidence of an effect for other outcomes (referral, re-exposure to violence, health measures, lack of harm arising from screening). Thus, while screening increases identification, there is insufficient evidence to justify screening in healthcare settings. Furthermore, there remains a need for studies comparing universal screening to case-finding (with or without advocacy or therapeutic interventions) for women's long-term wellbeing in order to inform IPV identification policies in healthcare settings.

The depression in women in pregnancy and postpartum period: A follow-up study

AIM

This was a follow-up study to determine postpartum depression (PPD) and its causes in a population previously evaluated in the first trimester of pregnancy.

METHODS

The study sample consisted of pregnant women who were evaluated in the first trimester and 360 women who were re-evaluated in the postpartum period. Detailed sociodemographic data were obtained from the women, and depression was assessed with the Edinburgh Postpartum Depression scale (EPDS) and Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (DSM) Axis I Disorders (SCID-I).

RESULTS

In this follow-up study, the prevalence of PPD was 35% (n = 126). A depressive disorder in the first trimester of pregnancy, previous mental disorder, somatic disorder, exposure to domestic violence during pregnancy, baby's staying in the incubator and not breastfeeding were predictors of PPD. Exposure to violence and a history of previous depression predicted depression both in pregnancy and in the postpartum period.

CONCLUSION

Depression rates are high in Eastern Turkey. Exposure to violence during pregnancy and the existence of a previous mental disorder were risk factors for perinatal depression in this study. Performing screening tests can identify women at risk of pregnancy-related depression. Prevention programs should be established in areas where the prevalence of depression is high.

Evaluation of healthcare use trends of high-risk female intimate partner violence victims

Introduction

Practitioners need more information about intimate partner violence (IPV) victims’ healthcare use trends. We used a novel data-linkage method and complaint categorization allowing us to evaluate IPV victims healthcare use trends compared to the date of their victimization.

Methods

This was a retrospective case series using data-linking techniques cross-referencing databases of Medicaid-eligible women between the ages of 16 and 55 years, an IPV Case Database for 2007 and the Florida State Agency for Healthcare Administration, which tracks hospital inpatient, ambulatory and emergency department (ED) use within the State of Florida. We analyzed resulting healthcare visits 1.5 years before and 1.5 years after the women’s reported IPV offense. Using all available claims data a ‘complaint category’ representing categories of presenting chief complaints was assigned to each healthcare visit. Analysis included descriptive statistics, correlation coefficients between time of offense and visits, and a logistic regression analysis.

Results

The 695 victims were linked with 4,344 healthcare visits in the four-year study period. The victims were young (46% in the 16–25 age group and 79% were younger than 35). Healthcare visits were in the ED (83%) rather than other healthcare sites. In the ED, IPV victims mostly had complaint categories of obstetrics and gynaecology-related visits (28.7%), infection-related visits (18.9%), and trauma-related visits (16.3%). ED use escalated approaching the victim’s date of offense (r=0.59, p<0.0001) compared to use of non-ED sites of healthcare use (r=0.07, p=0.5817). ED use deescalated significantly after date of reported offense for ED visits (r=0.50, p<0.0001) versus non-ED use (r=0.00, p=0.9958). The victims’ age group more likely to use the ED than any other age group was the 36–45 age group (OR 4.67, CI [3.26–6.68]).

Conclusion

IPV victims use the ED increasingly approaching their date of offense. Presenting complaints were varied and did not reveal unique identifiers of IPV victims. This novel method of database matching between claims data and government records has been shown to be a valid way to evaluate healthcare utilization of at-risk populations.

Screening women for intimate partner violence in healthcare settings

BACKGROUND

Intimate partner violence (IPV) damages individuals, their children, communities, and the wider economic and social fabric of society. Some governments and professional organisations recommend screening all women for intimate partner violence rather than asking only women with symptoms (case-finding); however, what is the evidence that screening interventions will increase identification, and referral to support agencies, or improve women's subsequent wellbeing and not cause harm?

OBJECTIVES

To assess the effectiveness of screening for intimate partner violence conducted within healthcare settings for identification, referral to support agencies and health outcomes for women.

SEARCH METHODS

We searched the following databases in July 2012: CENTRAL (2012, Issue 6), MEDLINE (1948 to September Week June Week 3 2012), EMBASE (1980 to Week 28 2012), MEDLINE In-Process (3 July 2012), DARE (2012, Issue 2), CINAHL (1937 to current), PsycINFO (1806 to June Week 4 2012), Sociological Abstracts (1952 to current) and ASSIA (1987 to October 2010). In addition we searched the following trials registers: metaRegister of Controlled Trials (mRCT) (to July 2012), and International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov, Australian New Zealand Clinical Trials Registry and the International Standard Randomised Controlled Trial Number Register to August 2010. We also searched the reference lists of articles and websites of relevant organisations.

SELECTION CRITERIA

Randomised or quasi-randomised trials assessing the effectiveness of IPV screening where healthcare professionals screened women face-to-face or were informed of results of screening questionnaires, compared with usual care ( which included screening for other purposes).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risk of bias in the trials and undertook data extraction. For binary outcomes, we calculated a standardised estimation of the risk ratio (RR) and for continuous data, either a mean difference (MD) or standardised mean difference (SMD). All are presented with a 95% confidence interval (CI).

MAIN RESULTS

We included 11 trials that recruited 13,027 women overall. Six of 10 studies were assessed as being at high risk of bias.When data from six comparable studies were combined (n = 3564), screening increased identification of victims/survivors (RR 2.33; 95% CI 1.40 to 3.89), particularly in antenatal settings (RR 4.26; 95% CI 1.76 to 10.31).Only three studies measured referrals to support agencies (n = 1400). There is no evidence that screening increases such referrals, as although referral numbers increased in the screened group, actual numbers were very small and crossed the line of no effect (RR 2.67; 95% CI 0.99 to 7.20).Only two studies measured women's experience of violence after screening (one at three months, the other at six, 12 and 18 months after screening) and found no significant reduction of abuse.Only one study measured adverse effects and data from this study suggested that screening may not cause harm. This same study showed a trend towards mental health benefit, but the results did not reach statistical significance.There was insufficient evidence on which to judge whether screening increases take up of specialist services, and no studies included economic evaluation.

AUTHORS' CONCLUSIONS

Screening is likely to increase identification rates but rates of referral to support agencies are low and as yet we know little about the proportions of false measurement (negatives or positives). Screening does not appear to cause harm, but only one study examined this outcome. As there is an absence of evidence of long-term benefit for women, there is insufficient evidence to justify universal screening in healthcare settings. Studies comparing screening versus case finding (with or without advocacy or therapeutic interventions) for women's long-term wellbeing would better inform future policies in healthcare settings.

Involving the health care system in domestic violence: what women want

PURPOSE Domestic violence is prevalent among women using primary health care services in Lebanon and has a negative effect on their health, yet physicians are not inquiring about it. In this study, we explored the attitudes of these women regarding involving the health care system in domestic violence management. METHODS We undertook a qualitative focus group study. Health care professionals in 6 primary health care centers routinely screened women for domestic violence using the HITS (Hurt, Insult, Threaten, Scream) instrument. At each center, 12 women who were screened (regardless of the result) were recruited to participate in a focus group discussion. RESULTS Most of the 72 women encouraged involvement of the health care system in the management of domestic violence and considered it to be a "socially accepted way to break the silence." Women expected health care professionals to have an "active conscience"; to be open minded, ready to listen, and unhurried; and to respect confidentiality. Additionally, they recommended mass media and community awareness campaigns focusing on family relationships to address domestic violence. CONCLUSIONS Addressing domestic violence through the health care system, if done properly, may be socially acceptable and nonoffensive even to women living in conservative societies such as Lebanon. The women in this study described characteristics of health professionals that would be conducive to screening and that could be extrapolated to the health care of immigrant Arab women.

The prevalence and correlates of depressive symptoms among adolescent mothers: results from a 17-year longitudinal study

The objective of the authors in this study was to examine the prevalence and correlates of elevated depressive symptoms in a 17-year cohort study of 173 women who were unmarried, pregnant adolescents between June 1988 and January 1990. Multiple logistic regression was used to estimate the associations between correlates and elevated depressive symptoms during five distinct developmental periods of the life course. Depressive symptoms were measured by the Brief Symptom Inventory depression subscale. The prevalence of elevated depressive symptoms in adolescent mothers significantly increased over the 17 years of the study from 19.8% to 35.2%. In adjusted analyses, antenatal depressive symptoms were positively and significantly associated with elevated depressive symptoms at every developmental period. Intimate partner violence was positively and significantly associated with elevated depressive symptoms during all but one developmental period. Other significant correlates of elevated depressive symptoms included welfare receipt, smoking, and parity, all of which were significant at some, but not other, developmental periods. Antenatal depressive symptoms and intimate partner violence were positively and significantly associated with elevated depressive symptoms. Given the public health consequences associated with maternal depression, clinical and community-based interventions should be developed to identify and to treat adolescent mothers at-risk for antenatal depression and intimate partner violence.

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

OBJECTIVE

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

DESIGN

Markov model-based cost-effectiveness analysis.

SETTING

General practices in two urban areas in the UK.

PARTICIPANTS

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

INTERVENTION

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

Current Controlled Trials, ISRCTN74012786.

Rates of femicide in women of different races, ethnicities, and places of birth: Massachusetts, 1993-2007

To describe the epidemiology of intimate partner violence (IPV) homicide in Massachusetts, an IPV mortality data set developed by the Massachusetts Department of Public Health was analyzed. The rates of death were estimated by dividing the number of decedents over the aged-matched population and Poisson regression was used to estimate the contribution of race, ethnicity, and foreign-born status to the risk of dying from IPV. Out of the total 270 women whose deaths were associated with IPV, 239 (89%) were killed by a male partner. Black women had a risk of dying from IPV of 16.2 per 1,000,000 person-years. Hispanic women also had a higher risk of dying from IPV than non-Hispanic women; incidence risk ratio of 9.7 (Poisson regression 95% confidence interval 6.8-13.8). IPV femicide disproportionately affected Black and Hispanic women. Agencies must consider the importance of providing culturally appropriate services to IPV survivors and their community.

Protection order petitioners' health care utilization

Little work has explored the extent to which female victims of intimate partner violence use medical and legal services. In this cross-sectional study of a sample of women seeking orders of protection at family court (N = 95), we report descriptive, self-report data on health care utilization and insurance coverage. Although 85% of the petitioners had private or public health insurance, 39% reported delayed medical care, and 14% had not obtained medical care of any kind. The response to address interpersonal violence victimization should attempt to connect women using the courts with needed health care services.

Primary care identification and referral to improve safety of women experiencing domestic violence (IRIS): protocol for a pragmatic cluster randomised controlled trial

BACKGROUND

Domestic violence, which may be psychological, physical, sexual, financial or emotional, is a major public health problem due to the long-term health consequences for women who have experienced it and for their children who witness it. In populations of women attending general practice, the prevalence of physical or sexual abuse in the past year from a partner or ex-partner ranges from 6 to 23%, and lifetime prevalence from 21 to 55%. Domestic violence is particularly important in general practice because women have many contacts with primary care clinicians and because women experiencing abuse identify doctors and nurses as professionals from whom they would like to get support. Yet health professionals rarely ask about domestic violence and have little or no training in how to respond to disclosure of abuse.

METHODS/DESIGN

This protocol describes IRIS, a pragmatic cluster randomised controlled trial with the general practice as unit of randomisation. Our trial tests the effectiveness and cost-effectiveness of a training and support programme targeted at general practice teams. The primary outcome is referral of women to specialist domestic violence agencies. Forty-eight practices in two UK cities (Bristol and London) are randomly allocated, using minimisation, into intervention and control groups. The intervention, based on an adult learning model in an educational outreach framework, has been designed to address barriers to asking women about domestic violence and to encourage appropriate responses to disclosure and referral to specialist domestic violence agencies. Multidisciplinary training sessions are held with clinicians and administrative staff in each of the intervention practices, with periodic feedback of identification and referral data to practice teams. Intervention practices have a prompt to ask about abuse integrated in the electronic medical record system. Other components of the intervention include an IRIS champion in each practice and a direct referral pathway to a named domestic violence advocate.

DISCUSSION

This is the first European randomised controlled trial of an intervention to improve the health care response to domestic violence. The findings will have the potential to inform training and service provision.

TRIAL REGISTRATION

ISRCTN74012786.

The experiences of Taiwanese women who have experienced domestic violence

BACKGROUND

Domestic violence has a history that stretches back before recorded time. It frequently has a lasting and traumatic impact on victims, families, and communities. According to the official statistics of many countries, most domestic violence victims are women who were assaulted by intimate male partners. This issue is gaining increasing attention in Taiwan's current society.

PURPOSE

The purpose of this study was to gain an empathic understanding of domestic violent abuse experienced by women in southern Taiwan. Perspectives were provided through the personal descriptions and views of the women interviewed.

METHODS

P.F. Colaizzi's (1976) descriptive phenomenological method was applied to conduct this study. A total of eight abused women from the southern Taiwan Domestic Violence and Sexual Assault Prevention Center participated in this study and associated in-depth interviews, which were tape-recorded, transcribed, and reviewed for accuracy by the interviewee. Verbatim manuscript transcriptions were then analyzed. Finally, major themes from extracted data were summarized.

RESULTS

The following four themes emerged: feeling sorry about their marriage, living in an unsafe environment, economic difficulties, and enduring unhappy lives.

CONCLUSIONS/IMPLICATIONS

These results may help health professionals understand the assault experiences and the nature of domestic violence from victims' viewpoints. This may also help health professionals obtain a comprehensive assessment and develop appropriate interventions for these abused women.

Differences in physical and mental health symptoms and mental health utilization associated with intimate-partner violence versus childhood abuse

BACKGROUND

There is ample evidence that both intimate-partner violence (IPV) and childhood abuse adversely affect the physical and mental health of adult women over the long term.

OBJECTIVE

The authors assessed the associations between abuse, symptoms, and mental health utilization.

METHOD

The authors performed a cross-sectional survey of 380 adult female, internal-medicine patients.

RESULTS

Although both IPV and childhood abuse were associated with depressive and physical symptoms, IPV was independently associated with physical symptoms, and childhood abuse was independently associated with depression. Women with a history of childhood abuse had higher odds, whereas women with IPV had lower odds, of receiving care from mental health providers.

CONCLUSION

IPV and childhood abuse may have different effects on women's symptoms and mental health utilization.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Domestic violence management in Malaysia: A survey on the primary health care providers

AIM

To assess the knowledge, attitudes and practices of primary health care providers regarding the identification and management of domestic violence in a hospital based primary health care setting.

METHOD

A survey of all clinicians and nursing staff of the outpatient, casualty and antenatal clinics in University Malaya Medical Centre using a self-administered questionnaire.

RESULTS

Hundred and eight out of 188 available staff participated. Sixty-two percent of the clinicians and 66.9% of the nursing staff perceived the prevalence of domestic violence within their patients to be very rare or rare. Majority of the clinicians (68.9%) reported asking their patients regarding domestic violence 'at times' but 26.2% had never asked at all. Time factor, concern about offending the patient and unsure of how to ask were reported as barriers in asking for domestic violence by 66%, 52.5% and 32.8% of the clinicians respectively. Clinicians have different practices and levels of confidence within the management of domestic violence. Victim-blaming attitude exists in 28% of the clinicians and 51.1% of the nursing staff. Less than a third of the participants reported knowing of any written protocol for domestic violence management. Only 20% of the clinicians and 6.8% of the nursing staff had ever attended any educational program related to domestic violence.

CONCLUSION

Lack of positive attitude and positive practices among the staff towards domestic violence identification and management might be related to inadequate knowledge and inappropriate personal values regarding domestic violence.

"You always end up feeling like you're some hypochondriac": intimate partner violence survivors' experiences addressing depression and pain

OBJECTIVE

Little is known regarding how providers should use information about intimate partner violence (IPV) to care for depressed patients. Our objective was to explore what depressed IPV survivors believe about the relationship between abuse, mental health, and physical symptoms and to elicit their recommendations for addressing depression.

DESIGN

Focus group study.

PATIENTS/PARTICIPANTS

Adult, English-speaking, female, Internal Medicine clinic patients with depressive symptoms and a history of IPV.

INTERVENTIONS

Thematic analysis using an inductive approach (consistent with grounded theory), at a semantic level, with an essentialist paradigm.

MEASUREMENTS AND MAIN RESULTS

Twenty three women participated in 5 focus groups. Although selected because of their depression, participants often felt their greatest concerns were physical. They acknowledged that their abuse history, depression, and physical complaints compound each other. They appreciated the need for health care workers to know about their depression and IPV history to get a "full picture" of their health, but they were often hesitant to discuss such issues with providers because of their fear that such information would make providers think their symptoms were "all in their head" or would encourage providers to discount their pain. Participants discussed difficulties related to trust and control in relationships with providers and gave recommendations as to how providers can earn their trust.

CONCLUSIONS

Understanding a patient's IPV history may allow providers to develop a better therapeutic relationship. To treat depression adequately, it is important for providers to reassure patients that they believe their physical symptoms; to communicate respect for patients' intelligence, experience, and complexity; and to share control.

Partner violence and health: results from the first national study on violence against women in Norway

BACKGROUND

Violence against women has long been considered a hidden health burden. Questions about violence have not been included in health surveys; hence, little is known about prevalence and the consequences for health in the general population. No national study has been conducted in Norway.

AIMS

To estimate the prevalence of partner violence in Norway and the relationship between victimization and somatic health and depression and anxiety and post-traumatic stress symptoms.

METHODS

Data collection was performed by Statistics Norway. Among a random sample of women aged 20-55 years, 2,407 women returned the questionnaire (63.3%), of whom 2,143 were ever-partnered. Selected demographic characteristics were obtained from registers.

RESULTS

In total, 26.8% of 2,143 ever-partnered women had experienced any violence by their partner during their lifetime, and 5.5% in the year before the study. Low educational level, being unmarried, separated or divorced, currently being unemployed, receiving social security benefits and having no children were significantly associated with reporting partner violence. Exposure to partner violence was associated with poor health, depressive and post-traumatic stress symptoms, gynaecological complaints, injuries, and disability, and remained so after controlling for age, education, unemployment, relationship break-up and low economic status.

CONCLUSIONS

Partner violence is common and was associated with a range of somatic and mental health problems. Thus, violence against women by their partners is an important public health concern.

Patterns in Relationship Violence Among African American Women: Future Research and Implications for Intervention

The impact of intimate partner violence (IPV) on those most at risk, HIV-positive women of color, has received little attention. This study examined IPV in HIV-positive and HIV-negative African American women. Victim characteristics and factors contributing to IPV and psychological sequelae were identified. Structured interviews were administered and analyzed at baseline, at 6 months, and at 12 months. HIV-positive women were less educated, were less employed, had lower incomes, had more depressive symptoms at all time points, and were more likely to report IPV at baseline and 6 months compared to HIV-negative women. Among HIV-positive depressed women, those reporting IPV were more depressed than those without IPV. Suggestions for studies with couples examining relationship dynamics, including risks for IPV and HIV transmission, and for interventions are discussed.

Asymptomatic bacteriuria and intimate partner violence in pregnant women

OBJECTIVE

This study was undertaken to determine whether the association of intimate partner violence with urinary tract infection and pyelonephritis in pregnancy is due to a higher rate of asymptomatic bacteriuria in those suffering intimate partner violence.

STUDY DESIGN

Women enrolling in prenatal care had urine collected for quantitative culture (n = 342) and completed 2 scales with a computer-based survey system: The Conflict Tactics Scale for verbal and physical abuse and the Castro survey for sexual abuse.

RESULTS

The prevalence of verbal abuse during pregnancy was 46.9%, physical abuse, 7.6%, sexual abuse 5.8%. No significant associations were seen between quantitative culture of uropathogens and verbal, physical, or sexual abuse.

CONCLUSION

It is unlikely that the reason for the association of urinary tract infection and intimate partner violence is due to a higher number of uropathogens present in the urine of women with verbal, physical, or sexual abuse.

Changes in the levels of knowledge and attitudes of dental hospital staff about domestic violence following attendance at an awareness raising seminar

OBJECTIVES

To assess changes in dental team knowledge and awareness about domestic violence following attendance at a brief training intervention.

MATERIALS AND METHODS

Seventy-five dental hospital staff at the University of Manchester Dental Hospital attended a two-hour session delivered by Manchester's City Wide NHS Domestic Violence Project manager. Participants completed identical questionnaires immediately before and after the session. Paired t-tests were conducted to determine changes in responses to individual questions before and after training. Independent sample t-tests were also conducted to compare mean responses by sex.

RESULTS

Statistically significant improvements were seen in 50% of attitude questions and 100% of knowledge questions. After training, there was improved recognition that interpersonal violence was a health issue and that the dental profession should be more involved in identification of abuse. There was also improved comfort asking about abuse and respondents were less afraid of offending the patient and less likely to blame the victims for being abused. Statistically significant sex differences at baseline were also seen for several items: females obtaining more correct answers at baseline than males.

CONCLUSIONS

Brief domestic violence training interventions can be effective in improving knowledge and attitudes amongst a dental team but could lead to false confidence in staff and should be followed by in-depth practical training and the development of appropriate processes for dealing with abuse victims.

Abuse disclosure in privately and medicaid-funded pregnant women

Disclosure of abuse by pregnant women can vary depending on whether the woman is assessed directly by a trained interviewer versus written questionnaires, and if she is asked repeatedly during the course of pregnancy. One thousand pregnant women were enrolled in a randomized clinical trial designed to assess the effects of a nursing case management intervention on the mental and physical well-being of pregnant women experiencing or at risk for abuse. Thirteen percent of the total study participants reported current abuse and/or abuse within the past year, with only 2% of those reporting that the abuse occurred during pregnancy. The incidence of reported abuse was much higher among Medicaid-funded women (28.9%) than privately insured women (8.7%). Regardless of source of payment, women reporting abuse were significantly younger, less educated, nonwhite with lower income, and had significantly higher stress and lower self-esteem than women not reporting abuse. A high incidence of women reporting intimate partner violence described being choked on the Danger Assessment Screen (34%). We strongly urge that choking be added to routine screening questions used during pregnancy and that the Danger Assessment tool is used for further evaluation of women who screen positive. In addition, we believe another barrier to reporting abuse was fear of being reported to child protective services, contributing to the overall low rate of abuse disclosure.

Domestic violence: a study among a group of Turkish women

OBJECTIVES

With this study we attempt to explore the reality of domestic violence, its prevalence, type and frequency among a group of Turkish women.

METHODS

This study was performed between October 2000 and May 2001 in the fourth largest city in Turkey. All women over the age of 15, who visited any of 50 health centres in different districts for different purposes, were asked to participate in the study. 506 of the participants who gave their consent were taken as a study group, and printed questionnaires were filled in during face-to-face interviews.

RESULTS

297 (58.7%) of the participants had experienced domestic violence at least once in their lifetime. The male partner was the primary violent person (49.5%), followed by mother and/or father (14.1%). The type of violence seen most was a combination of physical and psychological violence (45.5%). More than half of the women (58.6%) were experiencing domestic violence frequently and continuously. Reasons given for this violent behaviour were economic hardship (18.9%), followed by alcohol consumption by the violent person (18.5%), and inadequate family relations (15.8%). Of the victims 43.8% accepted this violence, but 26.6% reacted with violence. Women were not willing to abandon their relationships despite marital violence, because of their children (48.2%). Women's and men's higher educational attainments did indicate a decrease in the prevalence of domestic violence.

CONCLUSION

Reasons for continuing the abusive relationship and the effectiveness of the scarce support resources should be evaluated more seriously. The potential role of the primary healthcare provider in eliminating barriers for identification and assessment of domestic violence should not be forgotten. Otherwise, domestic violence will still remain a 'family matter', hidden and neglected.

Alcohol problems and the differentiation of partner, stranger, and general violence

To explore the relationship between alcohol problems and physical violence with partners and strangers, 457 college men and 958 college women with low, intermediate, or high scores on the Short Michigan Alcohol Screening Test reported conflict tactics on the Conflict Tactics Scale in the past year to and by partners and strangers. More men than women had high alcohol problems scores. Men with alcohol problems were more likely than other men to commit violence toward strangers or to partners and strangers. However, men with alcohol problems were not more likely than other men to commit violence toward partners only. Among women, alcohol problems had little relationship to committing violence or being the victim of violence.

Intimate Partner Violence Associated With Poor Health Outcomes in U.S. South Asian Women

To assess the associations between Intimate Partner Violence (IPV) victimization and health outcomes of South Asian women in Greater Boston. To explore the nature of the health experiences of victimized women in this population. Cross-sectional surveys with a community-based sample of women in relationships with males (n = 208) assessed demographics, IPV history, and health. In-depth interviews were conducted with a separate sample of women with a history of IPV (n = 23). Quantitative data were assessed by logistic regression, qualitative data by a grounded theory approach. Twenty-one percent of the quantitative sample reported IPV in the current relationship. Abused women were significantly more likely than those with no history of IPV in their current relationship to report poor physical health (95% CI = 1.3-12.0), depression (95% CI = 1.8-9.3), anxiety (95% CI = 1.3-6.4), and suicidal ideation (95% CI = 1.9-25.1). Qualitative subjects described how victimization resulted in injury and chronic health concerns and how IPV-induced depression and anxiety affected their sleep, appetite, energy, and wellbeing. Experiences of IPV are related to increased poor health among South Asian women. This elevated risk demands intervention. Healthcare providers should be trained to screen and refer South Asian patients for partner violence.

Depressive symptoms in women experiencing intimate partner violence

The study was a cross-sectional examination of African American women positive for intimate partner violence (IPV) who presented to the medical or psychiatric emergency department (ED) for treatment. African American women with a recent history of IPV who presented following an attempted suicide (n = 100) were compared to demographically comparable African American women who were IPV positive who had not attempted suicide and presented for treatment of another condition(n= 100). Women completed face-to-face interviews on several measures, including demographics and the Beck Depression Inventory-II (BDI-II). Overall, there were no demographic differences between cases and controls. Attempters reported statistically significant higher scores on all 21 BDI-II items than did nonattempters. Four BDI-II items had effect size values in the medium range: sadness, self-dislike, suicidal thoughts, and feelings of worthlessness. These four items can be used as a brief screen in the ED to detect female patients positive for IPV at increased risk for suicidal behavior.

Mutable influences on intimate partner abuse screening in health care settings: a synthesis of the literature

For more than a decade, professional medical and nursing associations have recommended universal screening for intimate partner abuse (IPA). This review of 44 studies examines IPA screening during this period. The purposes of the review are to (a) identify mutable influences on IPA screening, (b) summarize what is known about altering these influences, and (c) outline an agenda for improving IPA screening. Evidence to date indicates that screening is not universal. Promising approaches to improvement start with provider training and relatively simple environmental adjustments. Unanswered empirical questions include "What are the essential components of effective training? Which health care providers are best positioned to screen under which circumstances? Which of the untested mutable influences will further improve IPA screening practice?" The review leads to the following practice recommendations: (a) Interventions should focus on clinicians in training (e.g., medical residents), and (b) screening approaches must be tailored to various practice settings.

Survival of intimate partner violence as experienced by women

AIMS AND OBJECTIVES

The study set out to describe women's experiences of intimate partner violence, the consequences of such violence, the help they received and women's experiences of their survival.

BACKGROUND

Social and health professionals do not have sufficient ability to identify and help families who suffer from intimate partner violence. Methods for identifying and treating partner violence not have been developed adequately.

METHOD

The study was conducted in Finland by loosely formulated open-ended interviews with seven battered women. The data were analysed by inductive qualitative content analysis.

FINDINGS

Women had past experience of maltreatment and a distressing climate at their parental home. Women experienced both themselves and their spouse as having weak identities; their ideals, patterns of marriage and sexuality were different. Violence occurred in situations of disagreement. Women tried to strike a balance between independence and dependence in the relationship. The different forms of couple violence were interlinked. The women sought help when their health and social relationships got worse. An awareness of the problem, taking action, counselling and social relationships helped them survive. Religiousness was a factor that involved commitment to the couple relationship, made religious demands on women and promoted the recovery of integrity.

CONCLUSIONS

Intimate partner violence was associated with the family model, childhood experience of maltreatment, the partners' weak identity and conflicts between individualism and familism. Social and healthcare professionals need competence in early intervention and skills to discuss moral principles, sexuality, and violence in a way that is free of prejudice and condemning attitudes. Spiritual approaches in the context of interventions should be taken into consideration.

RELEVANCE TO CLINICAL PRACTICE

In a clinical context, nurses should be aware of the symptoms of violence, and they should have skills in dealing with intimate moral and spiritual issues.