Lorna O'Doherty

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 womens 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 doctors 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); womens 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 womens safety (5·1, 1·9-14·0; p=0·002) and childrens 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.

Screening women for intimate partner violence in healthcare settings: abridged Cochrane systematic review and meta-analysis.

Objective To examine the effectiveness of screening for intimate partner violence conducted within healthcare settings to determine whether or not screening increases identification and referral to support agencies, improves women’s wellbeing, decreases further violence, or causes harm. Design Systematic review and meta-analysis of trials assessing effectiveness of screening. Study assessment, data abstraction, and quality assessment were conducted independently by two of the authors. Standardised estimations of the risk ratios and 95% confidence intervals were calculated. Data sources Nine databases searched up to July 2012 (CENTRAL, Medline, Medline(R), Embase, DARE, CINAHL, PsycINFO, Sociological Abstracts, and ASSIA), and five trials registers searched up to 2010. Eligibility criteria for selecting studies Randomised or quasi-randomised trials of screening programmes for intimate partner violence involving all women aged ≥16 attending a healthcare setting. We included only studies in which clinicians in the intervention arm personally conducted the screening, or were informed of the screening result at the time of the consultation, compared with usual care (or no screening). Studies of screening programmes that were followed by structured interventions such as advocacy or therapeutic intervention were excluded. Results 11 eligible trials (n=13 027) were identified. In six pooled studies (n=3564), screening increased the identification of intimate partner violence (risk ratio 2.33, 95% confidence interval 1.39 to 3.89), particularly in antenatal settings (4.26, 1.76 to 10.31). Based on three studies (n=1400), we detected no evidence that screening increases referrals to domestic violence support services (2.67, 0.99 to 7.20). Only two studies measured women’s experience of violence after screening (three to 18 months after screening) and found no reduction in intimate partner violence. One study reported that screening does not cause harm. Conclusions Though screening is likely to increase identification of intimate partner violence in healthcare settings, rates of identification from screening interventions were low relative to best estimates of prevalence of such violence. It is uncertain whether screening increases effective referral to supportive agencies. Screening does not seem to cause harm in the short term, but harm was measured in only one study. As the primary studies did not detect improved outcomes for women screened for intimate partner violence, there is insufficient evidence for screening in healthcare settings. Studies comparing screening versus case finding, or screening in combination with therapeutic intervention for women’s long term wellbeing, are needed to inform the implementation of identification policies in healthcare settings.

Effect of Type and Severity of Intimate Partner Violence on Women’s Health and Service Use Findings From a Primary Care Trial of Women Afraid of Their Partners

Intimate partner violence (IPV) has major affects on women’s wellbeing. There has been limited investigation of the association between type and severity of IPV and health outcomes. This article describes socio-demographic characteristics, experiences of abuse, health, safety, and use of services in women enrolled in the Women’s Evaluation of Abuse and Violence Care (WEAVE) project. We explored associations between type and severity of abuse and women’s health, quality of life, and help seeking. Women (aged 16–50 years) attending 52 Australian general practices, reporting fear of partners in last 12 months were mailed a survey between June 2008 and May 2010. Response rate was 70.5% (272/386). In the last 12 months, one third (33.0%) experienced Severe Combined Abuse, 26.2% Physical and Emotional Abuse, 26.6% Emotional Abuse and/or Harassment only, 2.7% Physical Abuse only and 12.4% scored negative on the Composite Abuse Scale. A total of 31.6% of participants reported poor or fair health and 67.9% poor social support. In the last year, one third had seen a psychologist (36.6%) or had 5 or more general practitioner visits (34.3%); 14.7% contacted IPV services; and 24.4% had made a safety plan. Compared to other abuse groups, women with Severe Combined Abuse had poor quality of life and mental health, despite using more medications, counseling, and IPV services and were more likely to have days out of role because of emotional issues. In summary, women who were fearful of partners in the last year, have poor mental health and quality of life, attend health care services frequently, and domestic violence services infrequently. Those women experiencing severe combined physical, emotional, and sexual abuse have poorer quality of life and mental health than women experiencing other abuse types. Health practitioners should take a history of type and severity of abuse for women with mental health issues to assist access to appropriate specialist support.

A brief counselling intervention by health professionals utilising the ‘readiness to change’ concept for women experiencing intimate partner abuse: The weave project

Abstract This paper describes a brief counselling intervention based on the ‘readiness to change’ concept for women experiencing intimate partner violence, and an educational program for training primary care health professionals in the delivery of such an intervention. We present a synthesis of the literature on the Transtheoretical Model of Behaviour and the Psychosocial Readiness to Change Model as applied to intimate partner violence. We describe the intervention used in the weave trial, which draws on the educational and partner violence literature, as well as integrating key theoretical insights from the field of behaviour change. Practical steps for training health professionals are outlined from the authors’ experience and research.

What do Australian Women Experiencing Intimate Partner Abuse Want From Family and Friends

We analyzed the views of a diverse sample of women (N = 254) living in the state of Victoria, Australia, who were experiencing fear of an intimate partner. We explored the women’s views about their interactions with their family and friends to examine what women who have experienced fear of a partner or ex-partner want from their family and friends. The themes identified provide potentially useful guidance for what might be helpful and unhelpful communication strategies and behaviors for families and friends. Women experiencing intimate partner abuse find informal support invaluable, provided it is delivered in a helpful fashion. Helpful support is affirming, encouraging, validating, and understanding, and delivered with positive regard, empathy, and respect. Social contact and interaction are particularly appreciated, as is instrumental support such as financial help, housing, and child care. Women value both support that is directly related to abuse and support related to other areas of life.

Measuring life quality, physical function and psychological well-being in neurological illness

Abstract There is little in the literature comparing experiences of patients with disabling and uniformly terminal illness (e.g. amyotrophic lateral sclerosis) and illness characterized by episodic disability and prognostic uncertainty (e.g. multiple sclerosis). This study aimed to compare experiences of disability, quality of life (QoL) and psychological well-being in ALS and MS. One hundred patients with ALS and MS were interviewed at baseline and at six months. Variables measured included function, health related QoL, individualized QoL and psychological distress. Despite the divergent illness experiences of ALS and MS patients, groups did not differ on individualized QoL or mental well-being, and distress was in the normal range. Despite marked deterioration in ALS patients’ health, there was no change in mental well-being and QoL. Psychological well-being appeared more important in maintaining QoL (individualized QoL and mental aspects of health related QoL) than physical factors. At the individual level, there was evidence of psychological adaptation to deteriorating function, which underlined the role of specific illness related challenges in determining perceived life quality and emotional well-being. In conclusion, the complex interplay between psychosocial and illness specific factors such as certainty with regard to prognosis has considerable implications for well-being and life quality. Recognizing such factors is essential when designing clinical interventions to promote adjustment and self-management among patients with neurological conditions.

Fractured Identity in the Context of Intimate Partner Violence Barriers to and Opportunities for Seeking Help in Health Settings

Intimate partner violence has profound effects on women’s identities. However, detailed examination of how abuse affects identity is lacking. We interviewed 14 diverse women (Australia), applying social identity theory to analyze their experiences of identity and help-seeking in health settings. The destabilizing effect of violence on social identities was strongly supported. Women concealed abuse to preserve a public identity. However, when the violence threatened the most integrated identities, women unveiled an abuse identity, receiving mixed responses from health providers. A healing context where a woman can display an abuse identity safely is crucial to enable her to rebuild an integrated self-concept.

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

Intimate partner violence is a common but under-recognised issue for women attending primary care. There is a lack of studies looking at womens comfort to discuss and openness to getting help for health issues, including fear of a partner, in primary care. Female patients (aged 16-50 years) attending 55 general practitioners (GPs) in Victoria, Australia were mailed a brief survey that screened for health and lifestyle issues, comfort to discuss these issues and intention to get help in primary care. Needing physical activity and smoking were the issues women were most comfortable to discuss; followed by difficulty controlling what and/or how much is eaten, feeling down, depressed, hopeless or worried, and use of drugs or alcohol. Women were least comfortable to discuss fear of a partner and least likely to seek help for it from the GP or primary care nurse. However, as with the other issues, acceptability of being asked in a survey was high. All health and lifestyle issues predicted fear of a partner. Primary care practitioners should be aware of this complex major public health issue especially when carrying out preventive health care.

Authors’ reply to Whitehouse and Fabre

Unlike Whitehouse, we do not think that our findings will “discourage health professionals from identifying and signposting” as long as they receive regular and sustained training and resources on identification and appropriate responses.1 2 We are definitely not saying that clinicians should sit back and wait for disclosures of intimate partner violence. We agree with Fabre that case finding …

Quality of life in neurological illness: generic versus individualised indicators

Objectives?The aim of this study is to develop robust outcome measures, which draw on well-developed theoretical constructs, that measure parents perceived ability to manage their children and which are applicable in the UK context. An instrument to measure parenting self-efficacy will enable a rigorous evaluation of the effectiveness of different types of parenting programmes as well as pre- and post-course measures of individual programmes and will facilitate an evaluation of the longer-term effects on the well-being of parents and their children. Methods?Focus groups were conducted with a diverse range of parents and with parenting programme facilitators to discover what are the major challenges and difficulties surrounding parenting at different stages of being a parent from infancy through to school entry. We used the evidence base provided by the focus group discussions and from the literature on parenting and self-efficacy to inform the instrument. Self-efficacy statements were developed in Likert-format and a multi-method approach was used to test and refine the instrument. Instrument validity and cultural sensitivity were checked by a panel of experts from the fields of self-efficacy and parenting, and by parents. Internal and external reliability were analysed using SPSS. Results?In total 70 participants took part in twelve focus groups and a diverse range of consistent themes emerged surrounding behaviour management, self-control, self-acceptance, empathy and affection. Nine domain specific subscales of parenting self-efficacy were identified from the analysis of the focus group transcripts. Cronbachs alpha coefficients for the subscales ranged from 0.80 to 0.89, the full-scale alpha (82 items) was equal to 0.94. Spearmans correlation coefficients for a control group of parents ranged from rs?=?0.58, n?=?19, p<0.01 to rs?=?0.88, n?=?19, p<0.01. There was a significant difference in scores between parents identified as having parenting difficulties and the control group on all but one subscale. Conclusion?An instrument to measure parenting self-efficacy in the UK has been developed from the evidence provided by parents and parenting programme facilitators. The instrument has been developed from a sound theoretical framework and is currently being piloted to measure the effectiveness of parenting programmes in the UK.Objectives : The study was designed to investigate life satisfaction (l.s.) judgments as they occur spontaneously in everyday life, rather than being constructed in response to a researchers question. Methods : A convenience sample of 50 adults from Melbourne, Australia, was employed. Half had at least some university education; the other half did not. In an in-depth, structured interview, participants were asked to recall – if they could do so – an occasion when they had spontaneously made a judgment about their l.s. The circumstances in which the judgment had been made and the thoughts that had entered into it were elicited. Results : Main findings included : (a) All participants were able to recall an occasion when they had spontaneously made a l.s. judgment. (b) Judgments that life was good and that life was bad were equally common. (c) Judgments invariably involved comparisons with various standards (e.g., what one had versus what one wanted, what one had versus what one deserved, what one had versus what one expected to have). (d) However, upward and downward social comparisons were relatively rare. (e) Judgments were commonly based on events relating to just one or two areas of life, rather than a review of many different areas. (f) The areas of life involved were invariably those impacting very directly on participants. (g) While the thoughts entering into the judgment generally went beyond consideration just of a specific situation, they usually did not encompass large sweeps of time. (h) There was very little to distinguish judgments of more- and less-educated participants. Conclusions : Findings are compared and contrasted with those typically obtained using the more standard approach of asking participants to rate their 1.s.