If you were advising practitioners, would you recommend the use of advocacy interventions for women who experience domestic partner abuse? Please use your appraisal of the evidence to support your discussion.

Introduction

I would recommend the use of advocacy interventions for women experiencing domestic partner violence. Rivas et al., systematically review evidence on “the effectiveness of advocacy interventions” in diminishing or eradicating domestic violence and improving the “physical and psychosocial well-being” of domestically abused women (2015, pg.1). My critical appraisal of this review (Appendix) acts as the foundation of my argument; the conclusions and policy implications provided in Rivas et al.’s high quality review inform and add nuance to my recommendation.

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Based on the assessment I conducted on Rivas et al.’s review using the Joanna Briggs Institute’s Critical Appraisal Checklist for Systematic Reviews and Research Syntheses, it is evident that this systematic review is of high quality (2017). The authors put forth a clear review question, use adequate and appropriate methods, thoroughly assess risk of bias, and draw conclusions that align with the data and with their analysis of each study. The recommendation by Rivas et al. to not discontinue or withdraw pre-existing advocacy interventions is sound and the detailed contextual information the authors provide on when and for what outcomes advocacy interventions are most effective should be considered when giving advice to practitioners (2015, pg. 41). As a result, I recommend the use of brief, context specific, advocacy programmes implemented in tandem with other services to reduce physical abuse, anxiety, depression, and psychological distress among abused women.

To support my recommendation, I will first present two counterarguments and explain why they are not sufficient in refuting my position. I will then present reasoning for why advocacy interventions should be implemented to support women who experience domestic partner abuse.

 

Counterarguments

There are two main reasons why one could argue that practitioners should not use advocacy interventions for women who experience domestic partner abuse: (1) there is poor quality evidence and inconclusive evidence on effectiveness, and (2) there are alternative policy options that could be more effective and cost efficient than advocacy interventions.

  1. Poor quality evidence and inconclusive evidence on effectiveness

The risk of bias assessment in Rivas et al.’s systematic review finds that only one trial included in the review had a low risk of bias for all of the criteria used by the authors and that ten of the thirteen included studies were deemed to have a moderate to high risk of bias (2015, pg. 24 and 40).  Further, Rivas et al. conclude that there is “weak evidence” on advocacy intervention effectiveness (2015, pg. 41). However, given that the risk of bias assessment is transparent and thorough, the reader is able to understand the specific limitations of the evidence (outlined below) and use this understanding to inform how advocacy interventions should be implemented rather than claiming that they should not be implemented.

First, reporting omissions account for the majority of times a high risk of bias was identified in a particular category for a particular study; Rivas et al. claim that the evidence for the intervention effectiveness is “undermined because of difficulties in assessing the risk of bias for most trials in the review” (2015, pg. 40). An author neglecting to report an aspect of their research does not necessarily mean there were flaws in the study design and execution. Therefore, the issues with the quality of some studies is a reflection of reporting (i.e. not including all of the “details on how the studies have been conducted”) rather than violations of the risk of bias criteria (Rivas et al., 2015, pg. 41). These reporting issues are not enough to render advocacy interventions useless. Instead, reporting issues should be used to provide a realistic state of the evidence and to inform future research.

Second, even the studies that do report on the criteria assessed by the risk of bias tool and were deemed to have a high risk of violence should not be used to discredit the use of advocacy interventions. Due to the highly sensitive nature of domestic violence, the most rigorous research practices may not align with prioritizing research participants’ safety and best interest, and may not be possible to implement given the complex life situations experienced by victims of domestic violence (World Health Organization, 2012). For example, in many studies there was attrition for the “follow-up” portion of the research that impacted the risk of bias assessment (Rivas et al., 2015, pg. 23). In most instances, the reason for this attrition was that the researchers could not find the women who participated in the trials when these women were needed to complete follow-up assessments (Rivas et al., 2015, pg. 23). Abused women may face barriers to accessing private forms of communications (phone, mail, or email) and medical care due to monitoring and controlling behaviours by their partners (World Health Organization, 2012). The other reasons for loss of participants provided by Rivas et al. include: “refusal of women to carry on with the study, women returning to their abusive partner, women moving out of the area, and women having difficulties with transport, childcare, or living conditions” (2015, pg. 23). The challenges that emerge from the often precarious lives of domestic violence victims makes follow up in trials not only understandable but often unfeasible and must be considered when interpreting risk of bias assessments.

Further, in attempt to “do no harm”, it is reasonable to expect that RCTs in this topic area may violate ideal rigorous research practices. The most prominent consideration in domestic violence research “is the potential to inadvertently cause harm or distress” (Ellsberg, 2002, pg. 1599). In domestic violence research, female participants have, in the past, been “placed at risk as a result of inadequate attention to their safety” (Ellsberg, 2002, pg 1599). If a participant’s partner discovers that she has discussed her relationship with a researcher or health care professional, the respondent could be exposed to additional physical harm (Ellsberg, 2002). The World Health Organization’s (WHO) recommendations for conducting ethical studies on violence against women state that researchers should take every effort to try to minimize harm for participants; these extra efforts are often unique for research involving domestic violence victims (2001). For example, privacy protection has greater importance for abused women as confidentiality is imperative for ensuring women’s safety in their homes and communities (WHO, 2001). This WHO recommendation could violate ideal rigorous research practices as it could require researchers to change times or locations of the intervention and data collection, or alter the implementation of the intervention, to accommodate the participant (1999). Further, the WHO recommends that researchers in the field should be trained to assist research participants through providing referrals to short term support services when needed; these additional supports could act as confounding variables when measuring effect sizes (1999). Ultimately, efforts to ensure that no additional harm is inflicted on study participants could jeopardize key elements of RCT design such as true randomization, blinding, and contamination. I use this understanding to contextualize the risk of bias assessment conducted by Rivas et al.; the field of domestic violence research might not always be able to generate studies with low risk of bias but that should not impact the availability of supports to victims.

Third, a key reason for the inconclusiveness of the evidence is that the heterogenous nature of included studies – in terms of participant demographics, contexts, and outcome measures – made it so only a small number of studies could be meta-analysed (Rivas et al., 2015, pg. 26). Rivas et al. report that “eleven studies measured some form of abuse – physical, emotional, and/or sexual (eight scales), six assessed quality of life (three scales), and six measured depressions” (2015, pg. 3). These differences in the studies combined with the low power in each study hinders the ability of the analysis to find statistically significant effects (Rivas et al., 2015, pg. 28). This limitation does not necessarily point to the ineffectiveness of advocacy interventions and instead calls for more research and for researchers to conduct larger studies.

While it is not possible to definitively conclude that advocacy interventions are effective, Rivas et al.’s thorough and transparent review concludes that the “weak evidence” for advocacy interventions does not mean that “existing services should be withdrawn” (2015, pg. 41). Given that recent research efforts demonstrate growing support for advocacy intervention effectiveness, that there have been “positive point estimates” on the majority of the outcomes assessed, and that there has been no evidence indicating harm, advocacy interventions can be seen as promising (Rivas et al., 2015, pg. 41).

  1. Alternative options

It could be argued that advocacy interventions should not be implemented due to the fact that alternative options exist for supporting victims of domestic violence. For example, the WHO claims that training “health care providers in all aspects of intimate partner violence” is the most effective way to meet the specific needs of domestic violence victims (WHO, 2013, pg. 33). The issue with this approach is the poor existing state of care for women experiencing domestic violence (Colombini, 2008). Further, clinicians working in larger emergency or hospital systems may not be best placed to respond appropriately to victims even if they do receive training due to time and resource limitations and perceived priorities (Rivas et al, 2015, pg. 11).

“Screening practices” are additional ways to support domestic violence victims. However, a systematic review on screening practices found that while screening “increases identification”, there is “insufficient evidence to justify using this practice in health care settings” (O’Doherty, 2015, pg. 2). Psychological interventions or emergency shelter/housing provisions are additional services that could be provided to victims of domestic violence abuse (Feder, 2013). However, these interventions do not preclude the use of advocacy interventions. Specialized programs and services for domestic violence should be implemented in tandem with advocacy interventions to complement each other; advocates for domestic violence victims assist victims in being aware of and accessing services and stronger services will ensure that victims receive the support they need after they have received advocacy (Rivas et al., 2015, pg. 10).

While no cost effectiveness analysis of advocacy interventions exist, advocacy interventions could provide cost and time savings to medical professionals and hospitals. Further, if advocacy interventions reduce physical violence they should, in theory, reduce high emergency room costs. Rivas et al., provide evidence that: in Canada, abused women are three times more likely than women who are not victims of domestic violence to access medical services (Ratner, 1993); in the US, healthcare costs are much greater for victims of domestic violence when compared to non-abused women (Bonomi 2009b); and in the UK domestic violence costs 23 billion GBP per year (Walby, 2004).  Therefore, in addition to the importance of assisting victims in domestic violence, advocacy interventions could reduce the health care burdens of this type of violence.

 

Recommendation

Even though the existing research body has not fully established the benefits of advocacy interventions, Rivas et al. argue that active advocacy interventions should not be removed (2015). My recommendation, understanding that challenges exist with the quality and completeness of the evidence, echoes this sentiment. Domestic violence victims experience a variety of acute and long-term health, social, and economic impacts as a result of their violence (WHO, 2012). It is unreasonable to expect that one type of intervention will be able to address all of the challenges faced by victims. Therefore, this recommendation outlines the specific outcomes advocacy interventions are most effective in targeting and provides best practices for implementation.

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Based on the review of evidence conducted by Rivas et al., I recommend the use of brief advocacy programs implemented in tandem with other services and interventions to support domestic violence victims in reducing subsequent physical abuse and in reducing anxiety, depression, and psychological distress. The justification for this specific recommendation is as follows.

First, Rivas et al. find that the majority of studies included in their review report on physical violence as compared to other forms of abuse such as sexual or psychological abuse (2015, pg. 22). While the meta-analysis conducted by Rivas et al., did not point to any conclusive effect sizes in reducing physical violence, Tiwari’s 2005 study, deemed to have a low risk of bias, presented “striking evidence that the provision of a one-off session of advocacy led to a reduction in minor physical abuse, emotional abuse, and post-natal depression” (Rivas et al., 2015, pg. 40). While Tiwari’s study was not the only study that found positive effect evidence, it was the only study that found both statistically significant results and was deemed to have a low risk of bias, and therefore, provides trusting and promising indications that advocacy interventions are effective (Rivas et al., 2015, pg. 40).

Second, there is evidence that anxiety and psychological distress of victims of domestic violence can be reduced through advocacy interventions. Rivas et al. state that short term advocacy delivered within health care settings may reduce levels of “perceived stress” and may temporarily alleviate “anxiety and psychological distress” (2015, pg. 31 and 39). Further, three studies show evidence that brief advocacy can improve depressive symptoms and that “psychological distress” decreases in the short-term when “abused women attending a hospital emergency department receive a brief session of advocacy” (Rivas et al., 2015, pg. 39).

Third, brief advocacy interventions appear to be more effective than longer-term interventions. While there are several possibilities for this finding, it could be hypothesized that advocacy interventions are best delivered to victims of domestic violence who are in emergency situations or periods of crisis. Therefore, to successfully assist victims of domestic violence, advocacy interventions must be supplemented with additional programmes and policies to assist women in the long-term. Perhaps this means investing in sustainable, cost effective, and viable options for women and their families to leave abusive situations safely. Advocacy interventions will only be as successful as the resources and services that advocates are connecting victims of domestic violence to.

 

Conclusion: Evaluation of policy implementation

Implementing advocacy interventions in the ways described above provides a unique opportunity to evaluate and study advocacy effectiveness using recommendations and insights provided by Rivas et al.’s 2015 review.  First, it would provide the opportunity for researchers to conduct a study with increased power and longer follow up assessments – two key elements missing from existing studies evaluating advocacy interventions (Rivas et al., 2015, pg. 41). Second, there is a possibility of conducting a qualitative analysis to provide an enhanced and nuanced understanding of effectiveness. Domestic violence victims are operating in a context that may not always be conducive for randomization and quantitative measures. Qualitative research aimed at understanding the impacts of advocacy interventions on women could provide useful insight on their effectiveness and circumvent the barriers of other research methods. Ultimately, more support in the form of advocacy interventions and simultaneously more and better research on this type of support is required to adequately support victims of domestic violence.

References:

  • Bonomi, A. E., Anderson, M. L., Rivara, F. P., & Thompson, R. S. (2009). Health care utilization and costs associated with physical and nonphysical‐only intimate partner violence. Health services research44(3), 1052-1067.
  • Colombini, M., Mayhew, S., & Watts, C. (2008). Health-sector responses to intimate partner violence in low-and middle-income settings: a review of current models, challenges and opportunities. Bulletin of the World health Organization86, 635-642.
  • Ellsberg, M., & Heise, L. (2002). Bearing witness: ethics in domestic violence research. The lancet359(9317), 1599-1604.
  • Feder, G., Wathen, C. N., & MacMillan, H. L. (2013). An evidence-based response to intimate partner violence: WHO guidelines. Jama310(5), 479-480.
  • The Joanna Briggs Institute. Critical Appraisal Checklist for Systematic Reviews and Research Syntheses. 2017. https://www.joannabriggs.org/sites/default/files/2019-05/JBI_Critical_Appraisal-Checklist_for_Systematic_Reviews2017_0.pdf
  • O’Doherty, L., Hegarty, K., Ramsay, J., Davidson, L. L., Feder, G., & Taft, A. (2015). Screening women for intimate partner violence in healthcare settings. Cochrane database of systematic reviews, (7).
  • Ratner, P. A. (1993). The incidence of wife abuse and mental health status in abused wives in Edmonton, Alberta. Canadian journal of public health= Revue canadienne de sante publique84(4), 246-249.
  • Rivas, C., Ramsay, J., Sadowski, L., Davidson, L. L., Dunne, D., Eldridge, S., … & Feder, G. (2015). Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well‐being of women who experience intimate partner abuse. Cochrane database of systematic reviews, (12).
  • Walby, S. (2009). The cost of domestic violence: up-date 2009.
  • World Health Organization. (2001). Putting women first: Ethical and safety recommendations for research on domestic violence against women (No. WHO/FCH/GWH/01.1). Geneva: World Health Organization.
  • World Health Organization. (2013). World Health Organization. Responding to Intimate Partner Violence and Sexual Violence against Women: WHO Clinical and Policy Guidelines. Geneva: WHO, 2013.
  • World Health Organization. (2012). Understanding and addressing violence against women: Intimate partner violence (No. WHO/RHR/12.36). World Health Organization.

Appendix: Critical Appraisal of Rivas et al.’s article using the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews and Research Syntheses

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