Healthcare system responses to intimate partner violence in low and middle-income countries: evidence is growing and the challenges become clearer.

The damage to health caused by intimate partner violence demands effective responses from healthcare providers and healthcare systems worldwide. To date, most evidence for the few existing, effective interventions in use comes from high-income countries. Gupta et al. provide rare evidence of a nurse-delivered intimate partner violence screening, supportive care and referral intervention from a large-scale randomised trial in Mexican public health clinics. No difference was found in the primary outcome of reduction in intimate partner violence. There were significant short-term benefits in safety planning and mental health (secondary outcomes) for women in the intervention arm, but these were not sustained.This important study highlights the challenges of primary outcome choices in such studies, and further challenges for the sustainability of healthcare systems and healthcare provider interventions. These challenges include the role of theory for sustainability and the risk that baseline measures of intimate partner violence can wash out intervention effects. We emphasise the importance of studying the processes of adaptation, integration and coordination in the context of the wider healthcare system.Please see related article: https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-017-0880-y

Preventing and reducing violence against women: innovation in community-level studies

Intimate partner violence is a serious global problem that damages the health and prosperity of individuals, their families, community, and society. WHO endorses an ‘ecological model,’ which states that there are multi-level intersecting factors enabling perpetration and victimization of violence. Intervention science to prevent or reduce the problem is in its infancy, and the few existing intervention studies have been targeted at the individual level. In a recent study published in BMC Medicine, Abramsky et al. bring innovation to the field, targeting their intervention trial “SASA!” in Kampala Uganda at all ecological levels, but particularly at the community level. Recruiting and training both male and female community leaders and activists who enabled group and media discussions, the authors focused on the beneficial and abusive detrimental uses of power rather than commencing with the central issue of gender inequality. SASA! successfully reduced community attitudes to tolerance of violence and inequality, men’s sexual risk behaviors, and women’s experience of physical violence. The study also improved the communities’ response to victimized women. SASA! has promise for adaptation and replication in low, middle and high income countries. Please see related article: http://www.biomedcentral.com/1741-7015/12/122

Impact of violence against women on severe acute maternal morbidity in the intensive care unit, including neonatal outcomes: a case–control study protocol in a tertiary healthcare facility in Lima, Peru

Introduction Preventing and reducing violence against women (VAW) and maternal mortality are Sustainable Development Goals. Worldwide, the maternal mortality ratio has fallen about 44% in the last 25 years, and for one maternal death there are many women affected by severe acute maternal morbidity (SAMM) requiring management in the intensive care unit (ICU). These women represent the most critically ill obstetric patients of the maternal morbidity spectrum and should be studied to complement the review of maternal mortality. VAW has been associated with all-cause maternal deaths, and since many women (30%) endure violence usually exerted by their intimate partners and this abuse can be severe during pregnancy, it is important to determine whether it impacts SAMM. Thus, this study aims to investigate the impact of VAW on SAMM in the ICU. Methods and analysis This will be a prospective case-control study undertaken in a tertiary healthcare facility in Lima-Peru, with a sample size of 109 cases (obstetric patients admitted to the ICU) and 109 controls (obstetric patients not admitted to the ICU selected by systematic random sampling). Data on social determinants, medical and obstetric characteristics, VAW, pregnancy and neonatal outcome will be collected through interviews and by extracting information from the medical records using a pretested form. Main outcome will be VAW rate and neonatal mortality rate between cases and controls. VAW will be assessed by using the WHO instrument. Binary logistic followed by stepwise multivariate regression and goodness of fit test will assess any association between VAW and SAMM. Ethics and dissemination Ethical approval has been granted by the La Trobe University, Melbourne-Australia and the tertiary healthcare facility in Lima-Peru. This research follows the WHO ethical and safety recommendations for research on VAW. Findings will be presented at conferences and published in peer-reviewed journals

Social determinants and maternal exposure to intimate partner violence of obstetric patients with severe maternal morbidity in the intensive care unit: a systematic review protocol

Introduction: Maternal mortality is a potentially preventable public health issue. Maternal morbidity is increasingly of interest to aid the reduction of maternal mortality. Obstetric patients admitted to the intensive care unit (ICU) are an important part of the global burden of maternal morbidity. Social determinants influence health outcomes of pregnant women. Additionally, intimate partner violence has a great negative impact on women's health and pregnancy outcome. However, little is known about the contextual and social aspects of obstetric patients treated in the ICU. This study aimed to conduct a systematic review of the social determinants and exposure to intimate partner violence of obstetric patients admitted to an ICU. Methods and analysis: A systematic search will be conducted in MEDLINE, CINAHL, ProQuest, LILACS and SciELO from 2000 to 2016. Studies published in English and Spanish will be identified in relation to data reporting on social determinants of health and/or exposure to intimate partner violence of obstetric women, treated in the ICU during pregnancy, childbirth or within 42 days of the end of pregnancy. Two reviewers will independently screen for study eligibility and data extraction. Risk of bias and assessment of the quality of the included studies will be performed by using the Critical Appraisal Skills Programme (CASP) checklist. Data will be analysed and summarised using a narrative description of the available evidence across studies. This systematic review protocol will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guidelines. Ethics and dissemination: Since this systematic review will be based on published studies, ethical approval is not required. Findings will be presented at La Trobe University, in Conferences and Congresses, and published in a peer-reviewed journal

The power of social connection and support in improving health: lessons from social support interventions with childbearing women

<p>Abstract</p> <p>Background and objective</p> <p>Social support interventions have a somewhat chequered history. Despite evidence that social connection is associated with good health, efforts to implement interventions designed to increase social support have produced mixed results. The aim of this paper is to reflect on the relationship between social connectedness and good health, by examining social support interventions with mothers of young children and analysing how support was conceptualised, enacted and valued, in order to advance what we know about providing support to improve health.</p> <p>Context and approach</p> <p>First, we provide a brief recent history of social support interventions for mothers with young children and we critically examine what was intended by ‘social support’, who provided it and for which groups of mothers, how support was enacted and what was valued by women. Second, we examine the challenges and promise of lay social support approaches focused explicitly on companionship, and draw on experiences in two cluster randomised trials which aimed to improve the wellbeing of mothers. One trial involved a universal approach, providing befriending opportunities for all mothers in the first year after birth, and the other a targeted approach offering support from a ‘mentor mother’ to childbearing women experiencing intimate partner violence.</p> <p>Results</p> <p>Interventions providing social support to mothers have most often been directed to women seen as disadvantaged, or ‘at risk’. They have also most often been enacted by health professionals and have included strong elements of health education and/or information, almost always with a focus on improving parenting skills for better child health outcomes. Fewer have involved non-professional ‘supporters’, and only some have aimed explicitly to provide companionship or a listening ear, despite these aspects being what mothers receiving support have said they valued most. Our trial experiences have demonstrated that non-professional support interventions raise myriad challenges. These include achieving adequate reach in a universal approach, identification of those in need of support in any targeted approach; how much training and support to offer befrienders/mentors without ‘professionalising’ the support provided; questions about the length of time support is offered, how ‘closure’ is managed and whether interventions impact on social connectedness into the future. In our two trials what women described as helpful was not feeling so alone, being understood, not being judged, and feeling an increased sense of their own worth.</p> <p>Conclusion and implications</p> <p>Examination of how social support has been conceptualised and enacted in interventions to date can be instructive in refining our thinking about the directions to be taken in future research. Despite implementation challenges, further development and evaluation of non-professional models of providing support to improve health is warranted.</p

Ethical complexities of screening for depression and intimate partner violence (IPV) in intervention studies

<p>Abstract</p> <p>Background</p> <p>Intervention studies for depression and intimate partner violence (IPV) commonly incorporate screening to identify eligible participants. The challenge is that current ethical evaluation is largely informed by the four principle approach applying principles of beneficence, non-maleficence, and respect for justice and autonomy. We examine three intervention studies for IPV, postnatal depression (PND) and depression that used screening from the perspective of principlism, followed by the perspective of a narrative and relational approach. We suggest that a narrative and relational approach to ethics brings to light concerns that principlism can overlook.</p> <p>Discussion</p> <p>The justification most commonly used to incorporate screening is that the potential benefits of identifying intervention efficacy balance the risk of individual harm. However, considerable risks do exist. The discovery of new information may result in further depression or worries, people might feel burdened, open to further risk, unsure of whether to disclose information to family members and disappointed if they are allocated to a control group. This raises questions about study design and whether the principle of equipoise remains an adequate justification in studies with vulnerable groups. In addition, autonomy is said to be respected because participants give informed consent to participate. However, the context of where recruitment is undertaken has been shown to influence how people make decisions.</p> <p>Summary</p> <p>The four principles have been subjected to criticisms in recent years but they remain prominent in public health and medical research. We provide a set of simple, interrogative questions that are narrative and relationally driven which may assist to further evaluate the potential impacts of using screening to identify eligible research participants in intervention studies. A narrative and relational based approach requires seeing people as situated within their social and cultural contexts, and as existing within relationships that are likely to be affected by the results of screening information.</p

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 (&ge;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 &minus;2.9 to 5.9; psychological: &minus;0.2, 95% CI &minus;4.8 to 4.4,; social: &minus;1.4, 95% CI &minus;8.2 to 5.4; environmental: &minus;0.8, 95% CI &minus;4.0 to 2.5), mental health status (&minus;1.6, 95% CI &minus;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.</jats:sec