Identifying intimate partner violence when screening for health and lifestyle issues among women attending general practice

Identifying the barriers faced by obstetricians and registrars in screening or enquiry of intimate partner violence in pregnancy: A systematic review of the primary evidence

INTRODUCTION

Intimate partner violence (IPV) disproportionally affects women compared to men. The impact of IPV is amplified during pregnancy. Screening or enquiry in the antenatal outpatient setting regarding IPV has been fraught with barriers that prevent recognition and the ability to intervene.

AIMS

The aim of this systematic review was to determine the barriers that face obstetricians/gynaecologists regarding enquiry of IPV in antenatal outpatient settings. The secondary objective was to determine facilitators.

METHODS

Primary evidence was searched using Ovid MEDLINE, Ovid Maternity and Infant Care, PubMed and Proquest from 1993 to May 2023. The included studies comprised empirical studies published in English language targeting a population of doctors providing antenatal outpatient care. The review was PROSPERO-registered (CRD42020188994). Independent screening and review was performed by two authors. The findings were analysed thematically.

RESULTS

Nine studies addressing barriers and two studies addressing facilitators were included: three focus-group or semi-structured interviews, six surveys and two randomised controlled trials. Barriers for providers centred at the system level (time, training), provider level (personal beliefs, cultural bias, experience) and provider-perceived patient level (fear of offending, patient readiness to disclose). Increased experience and the use of validated tools were strong facilitators.

CONCLUSION

Barriers to screening reflect multi-level obstruction to the identification of women exposed to IPV. Although the antenatal outpatient clinic setting addresses a particular population vulnerable to IPV, the barriers for obstetricians are not unique. The use of validated cueing tools provides an evidence-based method to facilitate enquiry of IPV among antenatal women, assisting in identification by clinicians. Together with education and human resources, such aids build capacity in women and obstetric providers.

Barriers Faced by Australian and New Zealand Women When Sharing Experiences of Family Violence with Primary Healthcare Providers: A Scoping Review

Despite the Australian Government's attempts to reduce domestic violence (DV) incidences, impediments within the social and health systems and current interventions designed to identify DV victims may be contributing to female victims' reluctance to disclose DV experiences to their primary healthcare providers. This scoping review aimed to provide the state of evidence regarding reluctance to disclose DV incidents, symptoms and comorbidities that patients present to healthcare providers, current detection systems and interventions in clinical settings, and recommendations to generate more effective responses to DV. Findings revealed that female victims are reluctant to disclose DV because they do not trust or believe that general practitioners can help them to solve their issues, and they do not acknowledge that they are in an abusive relationship, and are unaware that they are in one, or have been victims of DV. The most common symptoms and comorbidities victims present with are sleep difficulties, substance use and anxiety. Not all GPs are equipped with knowledge about comorbidities signalling cases of DV. These DV screening programs are the most prominent intervention types within Australian primary health services and are currently not sufficiently nuanced nor sensitive to screen with accuracy. Finally, this scoping review provides formative evidence that in order for more accurate and reliable data regarding disclosure in healthcare settings to be collected, gender power imbalances in the health workforce should be redressed, and advocacy of gender equality and the change of social structures in both Australia and New Zealand remain the focus for reducing DV in these countries.

How Valid is the Question of Fear of a Partner in Identifying Intimate Partner Abuse? A Cross-Sectional Analysis of Four Studies

Intimate partner abuse (IPA) affects women's health, requiring accurate questions to identify the abuse. We investigated the accuracy of three questions about fear of an intimate partner in identifying exposure to IPA. We compared the sensitivity and specificity of these questions with the Composite Abuse Scale (CAS) using secondary data analysis of four existing studies. All studies recruited adult women from clinical settings, with sample sizes ranging from 1,257 to 5,871. We examined associations between demographic factors and fear through multivariate logistic regression, and analysis of the sensitivity and specificity of the questions about fear and IPA (CAS), generating a receiver operating curve (ROC). The prevalence of lifetime fear of a partner ranged from 9.5% to 26.7%; 14.0% of women reported fear in the past 12 months; and current fear ranged from 1.3% to 3.3%. Comparing the three questions, the question "afraid of a partner in the past 12 months" was considered the best question to identify IPA. This question had the greatest area under the ROC (0.80, 95% confidence interval (CI) = [0.78-0.81]) compared with "are you currently afraid" (range 0.57-0.61) or "have you ever been afraid" (range 0.66-0.77); and demonstrated better sensitivity (64.8%) and specificity (94.8%). Demographic factors associated with "fear of a partner in the past 12 months" included being divorced/separated (odds ratio [OR] = 8.49, 95% CI = [6.70-10.76]); having a low income (OR = 4.21, 95% CI = [3.46-5.13]); and having less than 12 years of education (OR = 2.48, 95% CI = [2.04-3.02]). The question "In the last 12 months did you ever feel frightened by what your partner says or does?" has potential to identify a majority of women experiencing IPA, supporting its utilization where more comprehensive measures are not possible.

Signs and symptoms of intimate partner violence in women attending primary care in Europe, North America and Australia: a systematic review and meta-analysis

BACKGROUND

Intimate partner violence (IPV) is a prevalent yet underdiagnosed health issue, and primary care practitioners are in a unique front-line position to provide care and counsel for the victims.

OBJECTIVE

To identify the signs and symptoms of women exposed to IPV who attended primary care, regardless motive of consultation.

METHODS

Systematic review and meta-analysis on Cochrane, PubMed, Embase and CINAHL between 1946 and 2020. Eligible studies had to be original quantitative research, on women aged >15 years, attending primary care settings in Europe, North America and Australia and interviewed on their status as victims of IPV and on their signs and symptoms.

RESULTS

Of 1791 articles identified, 57 were selected. Associations were found between IPV and signs and symptoms of depression [19 studies: overall odds ratio (OR) = 3.59, 95% confidence interval (CI; 2.7-4.7, I2 = 94.6%)], anxiety [9 studies: overall OR = 2.19, 95% CI (1.75-2.73, I2 = 84%)], gynaecological and/or sexually transmitted infections [6 studies: overall OR = 2.82, 95% CI (2.1-3.8, I2 = 41%)] and combination of somatic symptoms [5 studies: standard mean deviation = 0.795, 95% CI (0.62-0.97, I2 = 0%)].

CONCLUSIONS

Women exposed to IPV may present with clinical symptoms and signs other than bodily injury. Policy implications knowing these symptoms presented by women victims of IPV can help GPs identify and treat them.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018089857.

Two-year follow up of a cluster randomised controlled trial for women experiencing intimate partner violence: effect of screening and family doctor-delivered counselling on quality of life, mental and physical health and abuse exposure

OBJECTIVES

This was a 2-year follow-up study of a primary care-based counselling intervention (weave) for women experiencing intimate partner violence (IPV). We aimed to assess whether differences in depression found at 12 months (lower depression for intervention than control participants) would be sustained at 24 months and differences in quality in life, general mental and physical health and IPV would emerge.

DESIGN

Cluster randomised controlled trial. Researchers blinded to allocation. Unit of randomisation: family doctors.

SETTING

Fifty-two primary care clinics, Victoria, Australia.

PARTICIPANTS

Baseline: 272 English-speaking, female patients (intervention n=137, doctors=35; control n=135, doctors=37), who screened positive for fear of partner in past 12 months. Twenty-four-month response rates: intervention 59% (81/137), control 63% (85/135).

INTERVENTIONS

Intervention doctors received training to deliver brief, woman-centred counselling. Intervention patients were invited to receive this counselling (uptake rate: 49%). Control doctors received standard IPV information; delivered usual care.

PRIMARY AND SECONDARY OUTCOME MEASURES

Twenty-four months primary outcomes: WHO Quality of Life-Bref dimensions, Short-Form Health Survey (SF-12) mental health.

SECONDARY OUTCOMES

SF-12 physical health and caseness for depression and anxiety (Hospital Anxiety Depression Scale), post-traumatic stress disorder (Check List-Civilian), IPV (Composite Abuse Scale), physical symptoms (≥6 in last month). Data collected through postal survey. Mixed-effects regressions adjusted for location (rural/urban) and clustering.

RESULTS

No differences detected between groups on quality of life (physical: 1.5, 95% CI -2.9 to 5.9; psychological: -0.2, 95% CI -4.8 to 4.4,; social: -1.4, 95% CI -8.2 to 5.4; environmental: -0.8, 95% CI -4.0 to 2.5), mental health status (-1.6, 95% CI -5.3 to 2.1) or secondary outcomes. Both groups improved on primary outcomes, IPV, anxiety.

CONCLUSIONS

Intervention was no more effective than usual care in improving 2-year quality of life, mental and physical health and IPV, despite differences in depression at 12 months. Future refinement and testing of type, duration and intensity of primary care IPV interventions is needed.

TRIAL REGISTRATION NUMBER

ACTRN12608000032358.

Self-efficacy and doctor support as mediators of depression outcomes following counselling by family doctors for intimate partner violence

BACKGROUND

Previous research shows counselling delivered by trained family doctors reduces depression for women experiencing intimate partner violence (IPV). However, the potential for self-efficacy, doctor support and safety enquiry to mediate these effects has not been examined.

OBJECTIVES

To assess whether (i) women experiencing IPV and counselled by a trained family doctor report greater self-efficacy, perceived doctor support and enquiry about safety than those receiving usual care and (ii) whether self-efficacy, doctor support and enquiry mediate effects of counselling on depression for these women.

METHODS

Quantitative analysis as part of a process evaluation of data from a cluster randomized controlled trial of 272 female IPV survivors attending 52 Australian primary care clinics. Intervention group doctors were trained to deliver brief counselling. Comparison group doctors received standard IPV information. Intervention patients were invited to receive counselling from their trained doctor. Comparison patients received usual care. Data were collected at baseline, 6 and 12 months. Path analysis tested mediation effects from trial arm to depression via self-efficacy, doctor support and safety enquiry at 6 and 12 months, controlling for baseline and abuse level.

RESULTS

At 6 months, mean perceived doctor support was higher for intervention than comparison patients and mediated depression effect. At 12 months, mean self-efficacy was higher for intervention than comparison patients and mediated depression effect. Mediation effects for doctor enquiry were non-significant.

CONCLUSIONS

Counselling by trained family doctors can help increase support and self-efficacy of women who have experienced IPV, mediating reduced depression.

The impact of intimate partner violence on forgone healthcare: a population-based, multicentre European study

BACKGROUND

To examine the relationship between forgone healthcare and involvement in intimate partner violence (IPV) as victims, perpetrators or both.

METHODS

This cross-sectional multicentre study assessed community non-institutionalized residents (n = 3496, aged 18-64) randomly selected from six European cities: Athens, Budapest, London, Östersund, Porto, Stuttgart. A common questionnaire was used, including self-reports of IPV and forgone healthcare ('Have you been in need of a certain care service in the past year, but did not seek any help?'). Odds ratios (ORs), 95% confidence intervals (CIs) were computed fitting logistic regression models adjusted for city, chronic disease, self-assessed health status and financial strain.

RESULTS

Participants experiencing past year IPV (vs. no violence) reported more often to forgone healthcare (n = 3279, 18.6% vs. 15.3%, P = 0.016). IPV experienced as both a victim and perpetrator was associated with forgone healthcare (adjusted OR, 95%CI: 1.32, 1.02-1.70).

CONCLUSION

IPV was associated with forgone healthcare, particularly for those experiencing violence as both victims and perpetrators. Results suggest that preventing IPV among adults may improve timely healthcare uptake.

Longitudinal Changes in Self-Efficacy, Mental Health, Abuse, and Stages of Change, for Women Fearful of a Partner: Findings From a Primary Care Trial (WEAVE)

Women seeking healthcare while experiencing intimate partner violence (IPV) often report a mismatch between healthcare received and desired. An increase in detection of women experiencing IPV through routine screening has not consistently shown a parallel increase in uptake of referrals or decreased abuse. This study investigates relationships between women's stage of change (SOC), mental health, abuse, social support, and self-efficacy. This study used data from a randomized-controlled trial (RCT) of an intervention to improve outcomes for women afraid of their partners ( n = 225; WEAVE). Women's progress toward change was categorized into pre-contemplation/contemplation (pre-change SOC) or preparation/action/maintenance of change (change-related SOC). Characteristics of women ending the 2-year study in pre-change SOC were compared with those always in change-related and those ending in change-related SOC. Variables were analyzed using multinomial logistic regressions at baseline, 6, 12, and 24 months. Compared with women in pre-change SOC, women always in change-related SOC or ending in change-related SOC are significantly more likely to have higher levels of self-efficacy at 6 (AdjOR = 1.19, confidence interval [CI] = [1.08, 1.30]) and 24 months (AdjOR = 1.21, CI = [1.04, 1.40]). Women always in change-related SOC are always significantly less likely to live with an intimate partner. Women ending in change-related SOC are less likely to live with a partner at 12 (AdjOR = 0.30, CI = [0.12, 0.75]) and 24 (AdjOR = 0.22, CI = [0.06, 0.80]) months. Clinicians should focus on enhancing abused women's self-efficacy, supporting them to create and maintain positive changes.

Vulnerability to intimate partner violence and poor mental health in the first 4-year postpartum among mothers reporting childhood abuse: an Australian pregnancy cohort study

The purpose of this study was to investigate intergenerational patterns of abuse and trauma and the health consequences for women in the early childbearing years. A prospective pregnancy cohort of 1507 nulliparous women (≦24 weeks gestation) were recruited in Melbourne, Australia, 2003-2005. Follow-up was scheduled in late pregnancy, 3-, 6- and 12-month and 4-year postpartum. Childhood abuse was retrospectively reported at 4-year postpartum using the Child Maltreatment History Self Report. Intimate partner violence (IPV) was assessed at 1- and 4-year postpartum with the Composite Abuse Scale. Maternal depressive symptoms were assessed in all follow-ups using the Edinburgh Postnatal Depression Scale. Multivariable logistic regression was used to examine associations between childhood abuse, maternal mental health and IPV. Childhood abuse was reported by 41.1 % of women. In the 4 years after having their first child, 28.2 % of women reported IPV, 25.2 % depression and 31.6 % anxiety. Childhood abuse was associated with odds of depression or anxiety 1.5-2.6 times greater and 1.8-3.2 times greater for IPV. Childhood physical abuse remained significantly associated with depression and anxiety in pregnancy and postpartum after adjusting for IPV and stressful life events, while sexual abuse remained significantly associated only with anxiety. Women who begin childbearing with a history of childhood abuse are more vulnerable to IPV and poor mental health. All health care services and agencies in contact with children, young people and families should have adequate training to identify trauma associated with abuse and IPV and provide first line supportive care and referral.

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).

Health implications of partner violence against women in Ghana

This article explores the health implications of partner violence against women in Ghana using data from northern Ghana. Face-to-face structured interviews were conducted with a sample of 443 women contacted at health facilities in the northern region. Results indicate that 7 out of 10 women have experienced intimate partner violence (IPV) within the past 12 months; 62% had experienced psychological violence, 29% had experienced physical violence, and 34% had experienced sexual violence. Participants reported health problems associated with violence, including injury, thoughts of suicide, sleep disruption, and fear of partner (FP). Logistic regression analyses showed that women who reported physical, psychological, and sexual violence, respectively, had 3.94 times, 10.50 times, and 2.21 times the odds of reporting thoughts of suicide, whereas the odds that women who reported physical, psychological, and sexual violence would report sleep disruption were 4.82 times higher, 4.44 times higher, and 2.50 times higher, respectively. However, only physical and psychological violence predicted the odds of FP. This study shows that IPV is a health risk factor among women in Ghana. Measures that should be designed to improve the health of women experiencing marital violence are suggested.

Screening and counselling in the primary care setting for women who have experienced intimate partner violence (WEAVE): a cluster randomised controlled trial

BACKGROUND

Evidence for a benefit of interventions to help women who screen positive for intimate partner violence (IPV) in health-care settings is limited. We assessed whether brief counselling from family doctors trained to respond to women identified through IPV screening would increase women's quality of life, safety planning and behaviour, and mental health.

METHODS

In this cluster randomised controlled trial, we enrolled family doctors from clinics in Victoria, Australia, and their female patients (aged 16-50 years) who screened positive for fear of a partner in past 12 months in a health and lifestyle survey. The study intervention consisted of the following: training of doctors, notification to doctors of women screening positive for fear of a partner, and invitation to women for one-to-six sessions of counselling for relationship and emotional issues. We used a computer-generated randomisation sequence to allocate doctors to control (standard care) or intervention, stratified by location of each doctor's practice (urban vs rural), with random permuted block sizes of two and four within each stratum. Data were collected by postal survey at baseline and at 6 months and 12 months post-invitation (2008-11). Researchers were masked to treatment allocation, but women and doctors enrolled into the trial were not. Primary outcomes were quality of life (WHO Quality of Life-BREF), safety planning and behaviour, mental health (SF-12) at 12 months. Secondary outcomes included depression and anxiety (Hospital Anxiety and Depression Scale; cut-off ≥8); women's report of an inquiry from their doctor about the safety of them and their children; and comfort to discuss fear with their doctor (five-point Likert scale). Analyses were by intention to treat, accounting for missing data, and estimates reported were adjusted for doctor location and outcome scores at baseline. This trial is registered with the Australian New Zealand Clinical Trial Registry, number ACTRN12608000032358.

FINDINGS

We randomly allocated 52 doctors (and 272 women who were eligible for inclusion and returned their baseline survey) to either intervention (25 doctors, 137 women) or control (27 doctors, 135 women). 96 (70%) of 137 women in the intervention group (seeing 23 doctors) and 100 (74%) of 135 women in the control group (seeing 26 doctors) completed 12 month follow-up. We detected no difference in quality of life, safety planning and behaviour, or mental health SF-12 at 12 months. For secondary outcomes, we detected no between-group difference in anxiety at 12 months or comfort to discuss fear at 6 months, but depressiveness caseness at 12 months was improved in the intervention group compared with the control group (odds ratio 0·3, 0·1-0·7; p=0·005), as was doctor enquiry at 6 months about women's safety (5·1, 1·9-14·0; p=0·002) and children's safety (5·5, 1·6-19·0; p=0·008). We recorded no adverse events.

INTERPRETATION

Our findings can inform further research on brief counselling for women disclosing intimate partner violence in primary care settings, but do not lend support to the use of postal screening in the identification of those patients. However, we suggest that family doctors should be trained to ask about the safety of women and children, and to provide supportive counselling for women experiencing abuse, because our findings suggest that, although we detected no improvement in quality of life, counselling can reduce depressive symptoms.

FUNDING

Australian National Health and Medical Research Council.