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Meta-Analysis
. 2015 Dec 3;2015(12):CD005043.
doi: 10.1002/14651858.CD005043.pub3.

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

Carol Rivas  1 , Jean Ramsay, Laura Sadowski, Leslie L Davidson, Danielle Dunne, Sandra Eldridge, Kelsey Hegarty, Angela Taft, Gene Feder
Affiliations
Meta-Analysis

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

Carol Rivas et al. Cochrane Database Syst Rev. .

Abstract

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.

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Conflict of interest statement

Carol Rivas was partly funded by the National Institute for Health Research (NIHR) applied research programme funding stream. The views and opinions do not not necessarily reflect those of the NIHR, NHS, or the Department of Health (England). Gene Feder and Jean Ramsay's institution received payment from Socialforsksnings Institut (SFI) Nordic Campbell Centre Denmark, for submitting an edited version of the 2009 review to the Campbell Collaboration. Laura Sadowski has received funds for her participation in reviewing the evidence of interventions to reduce intimate partner violence for the British Medical Journal (BMJ) and the World Health Organization (WHO). Leslie Davidson ‐ none known. Danielle Dunne ‐ none known. Kelsey Hegarty's institution received funds from the National Health and Medical Research Council (NHMRC) for her work on Hegarty 2013. Kelsey received funds from a General Practice in Victoria for a training programme on intimate partner violence for general practitioners. Kelsey has also received funds for expenses from WHO, for her work in a guideline group on intimate partner violence. Angela Taft and Kelsey Hegarty declare they are authors on Taft 2011 and had no part in the assessment of eligibility, assessment of risk of bias or data extraction of this study. Angela received funds from National Health and Medical Research Council to conduct the MOSAIC trial and funds from the Australian Research Council and VicHealth to conduct the MOVE trial (bit.ly/1fpQPFw). Gene Feder, Sandra Eldridge and Jean Ramsay are authors of the Feder 2011 trial, which was not eligible for inclusion in this review. Cathy Bennett and Carol Rivas assessed the eligibility of studies for inclusion. Gene was not required to resolve any disagreements with regards to this trial. Gene is part of the steering group for Identification and Referral to Improve Safety (IRIS), a programme that can be commissioned in the United Kingdom to train general practices and provide a referral pathway to advocacy for women experiencing domestic violence. His employer, the University of Bristol, receives an annual consultancy fee for his involvement with IRIS. The study was not included in this review update. Gene is a Principal Investigator on domestic violence research studies, funded by grants to his University from the National Institute of Health Research, the UK Department of Health Policy Research Programme and the National School for Primary Care Research. Gene and his organisation receives funds for his consultancy work with the National Institute for Health and Care Excellence (NICE) and for chairing the Domestic Violence Programme Development Group there. He has received royalties for an academic book on domestic violence and health. Gene's university has received fees from the Health Foundation for domestic violence educational programmes that he has developed.

Figures

1
1
Risk of bias summary: review authors' judgements about each risk of bias item for each included study. Red circles with minus signs indicate high risk, green circles with plus signs indicate low risk, and yellow circles with question marks indicate unclear risk of bias.
2
2
Review flow diagram. IPV: intimate partner violence; RCT: randomised controlled trial.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
Logic model summarising results for brief advocacy interventions.
5
5
Logic model summarising results for intense advocacy interventions. PTSD: Post Traumatic Stress Disorder.
1.1
1.1. Analysis
Comparison 1 Physical abuse, Outcome 1 Brief advocacy.
1.2
1.2. Analysis
Comparison 1 Physical abuse, Outcome 2 Brief advocacy (dichotomous outcome) (up to 12 months follow‐up).
1.3
1.3. Analysis
Comparison 1 Physical abuse, Outcome 3 Brief advocacy (mean change).
1.4
1.4. Analysis
Comparison 1 Physical abuse, Outcome 4 Intensive advocacy.
1.5
1.5. Analysis
Comparison 1 Physical abuse, Outcome 5 Intensive advocacy (dichotomous outcome).
1.6
1.6. Analysis
Comparison 1 Physical abuse, Outcome 6 Intensive advocacy: missing reassigned (dichotomous outcome) (up to 12 months follow‐up).
1.7
1.7. Analysis
Comparison 1 Physical abuse, Outcome 7 Any advocacy.
1.8
1.8. Analysis
Comparison 1 Physical abuse, Outcome 8 Any advocacy (dichotomous outcome) (up to 12 months follow‐up).
2.1
2.1. Analysis
Comparison 2 Sexual abuse, Outcome 1 Brief advocacy (up to 12 months follow‐up).
2.2
2.2. Analysis
Comparison 2 Sexual abuse, Outcome 2 Brief advocacy (mean change) (up to 12 months follow‐up).
2.3
2.3. Analysis
Comparison 2 Sexual abuse, Outcome 3 Brief advocacy (dichotomous outcome) (up to 12 months follow‐up).
3.1
3.1. Analysis
Comparison 3 Emotional abuse, Outcome 1 Brief advocacy.
3.2
3.2. Analysis
Comparison 3 Emotional abuse, Outcome 2 Brief advocacy (mean change) (up to 12 months follow‐up).
3.3
3.3. Analysis
Comparison 3 Emotional abuse, Outcome 3 Intensive advocacy.
3.4
3.4. Analysis
Comparison 3 Emotional abuse, Outcome 4 Intensive advocacy (dichotomous outcome) (up to 12 months follow‐up).
3.5
3.5. Analysis
Comparison 3 Emotional abuse, Outcome 5 Any advocacy.
4.1
4.1. Analysis
Comparison 4 Risk of homicide, Outcome 1 Brief advocacy.
5.1
5.1. Analysis
Comparison 5 Risk of work harassment, Outcome 1 Brief advocacy.
6.1
6.1. Analysis
Comparison 6 Overall abuse, Outcome 1 Brief advocacy (up to 12 months follow‐up).
6.2
6.2. Analysis
Comparison 6 Overall abuse, Outcome 2 Intensive advocacy (up to 12 months follow‐up).
6.3
6.3. Analysis
Comparison 6 Overall abuse, Outcome 3 Intensive advocacy (dichotomous outcome) (up to 12 months follow‐up).
6.4
6.4. Analysis
Comparison 6 Overall abuse, Outcome 4 Any advocacy (up to 12 months follow‐up).
7.1
7.1. Analysis
Comparison 7 Quality of life, Outcome 1 Brief advocacy: 2 summary component subscales.
7.2
7.2. Analysis
Comparison 7 Quality of life, Outcome 2 Brief advocacy: 8 subscales (mean change).
7.3
7.3. Analysis
Comparison 7 Quality of life, Outcome 3 Intensive advocacy: 2 summary component subscales.
7.4
7.4. Analysis
Comparison 7 Quality of life, Outcome 4 Intensive advocacy: overall.
7.5
7.5. Analysis
Comparison 7 Quality of life, Outcome 5 Any advocacy: 2 summary component subscales.
8.1
8.1. Analysis
Comparison 8 Depression, Outcome 1 Brief advocacy (up to 12 months follow‐up).
8.2
8.2. Analysis
Comparison 8 Depression, Outcome 2 Brief advocacy (dichotomous outcome) (up to 12 months follow‐up).
8.3
8.3. Analysis
Comparison 8 Depression, Outcome 3 Intensive advocacy.
8.4
8.4. Analysis
Comparison 8 Depression, Outcome 4 Intensive advocacy (dichotomous outcome) (up to 12 months follow‐up).
8.5
8.5. Analysis
Comparison 8 Depression, Outcome 5 Any advocacy (up to 12 months follow‐up).
8.6
8.6. Analysis
Comparison 8 Depression, Outcome 6 Any advocacy (dichotomous outcome) (up to 12 months follow‐up).
9.1
9.1. Analysis
Comparison 9 Anxiety, Outcome 1 Brief advocacy (up to 12 months follow‐up).
9.2
9.2. Analysis
Comparison 9 Anxiety, Outcome 2 Intensive advocacy.
9.3
9.3. Analysis
Comparison 9 Anxiety, Outcome 3 Intensive advocacy (mean change) (up to 12 months follow‐up).
9.4
9.4. Analysis
Comparison 9 Anxiety, Outcome 4 Any advocacy (up to 12 months follow‐up).
10.1
10.1. Analysis
Comparison 10 Chronic pain, Outcome 1 Brief advocacy (up to 12 months follow‐up).
11.1
11.1. Analysis
Comparison 11 Chronic fatigue, Outcome 1 Brief advocacy (up to 12 months follow‐up).
12.1
12.1. Analysis
Comparison 12 Low birth weight, Outcome 1 Brief advocacy (dichotomous outcome).
13.1
13.1. Analysis
Comparison 13 Birth weight (grams), Outcome 1 Brief advocacy.
14.1
14.1. Analysis
Comparison 14 Pre‐term birth, Outcome 1 Brief advocacy (dichotomous outcome).
15.1
15.1. Analysis
Comparison 15 Gestational age (weeks) at delivery, Outcome 1 Brief advocacy.
16.1
16.1. Analysis
Comparison 16 Post‐traumatic stress, Outcome 1 Brief advocacy (up to 12 months follow‐up).
17.1
17.1. Analysis
Comparison 17 Perception of stress, Outcome 1 Brief advocacy (up to 12 months follow‐up).
18.1
18.1. Analysis
Comparison 18 Self efficacy, Outcome 1 Intensive advocacy.
19.1
19.1. Analysis
Comparison 19 Self esteem, Outcome 1 Intensive advocacy (up to 12 months follow‐up).
20.1
20.1. Analysis
Comparison 20 Perceived social support, Outcome 1 Brief advocacy (up to 12 months follow‐up).
20.2
20.2. Analysis
Comparison 20 Perceived social support, Outcome 2 Intensive advocacy.
20.3
20.3. Analysis
Comparison 20 Perceived social support, Outcome 3 Intensive advocacy (mean change).
20.4
20.4. Analysis
Comparison 20 Perceived social support, Outcome 4 Any advocacy (up to 12 months follow‐up).
21.1
21.1. Analysis
Comparison 21 Independence from abuser, Outcome 1 Intensive advocacy (dichotomous outcome).
21.2
21.2. Analysis
Comparison 21 Independence from abuser, Outcome 2 Intensive advocacy: missing reassigned (up to 12 months follow‐up) (dichotomous outcome).
22.1
22.1. Analysis
Comparison 22 Emotional attachment to abuser, Outcome 1 Intensive advocacy.
23.1
23.1. Analysis
Comparison 23 Use of safety behaviours, Outcome 1 Brief advocacy.
24.1
24.1. Analysis
Comparison 24 Use of resources, Outcome 1 Brief advocacy.
25.1
25.1. Analysis
Comparison 25 Difficulty obtaining resources, Outcome 1 Intensive advocacy.
See this image and copyright information in PMC

Update of

References

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Johnson 2011 {published data only}
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References to studies awaiting assessment

Bair‐Merritt 2010 {published and unpublished data}
    1. Bair‐Merritt MH, Jennings JM, Chen R, Burrell L, McFarlane E, Fuddy L, et al. Reducing maternal intimate partner violence after the birth of a child: a randomized controlled trial of the Hawaii Healthy Start home visitation program. Archives of Pediatric and Adolescent Medicine 2010;164(1):16‐23. - PMC - PubMed
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Prosman 2014 {published data only (unpublished sought but not used)}
    1. Prosman MA, Lo Fo Wong SH, Römkens R, Lagro‐Janssen ALM. ‘I am stronger, I'm no longer afraid…’, an evaluation of a home‐visiting mentor mother support programme for abused women in primary care. Scandinavian Journal of Caring Sciences 2014;28(4):724–31. [PUBMED: 24251372] - PubMed

References to ongoing studies

Lako 2013 {published data only}
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NCT01207258 {published data only}
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NCT01661504 {published data only}
    1. NCT01661504. Evaluating violence against women screening in Mexico. https://clinicaltrials.gov/show/NCT01661504 (accessed 4 September 2015).

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