Psychosocial interventions for survivors of rape and sexual assault experienced during adulthood.

BACKGROUND: Exposure to rape, sexual assault and sexual abuse has lifelong impacts for mental health and well-being. Prolonged Exposure (PE), Cognitive Processing Therapy (CPT) and Eye Movement Desensitisation and Reprocessing (EMDR) are among the most common interventions offered to survivors to alleviate post-traumatic stress disorder (PTSD) and other psychological impacts. Beyond such trauma-focused cognitive and behavioural approaches, there is a range of low-intensity interventions along with new and emerging non-exposure based approaches (trauma-sensitive yoga, Reconsolidation of Traumatic Memories and Lifespan Integration). This review presents a timely assessment of international evidence on any type of psychosocial intervention offered to individuals who experienced rape, sexual assault or sexual abuse as adults. OBJECTIVES: To assess the effects of psychosocial interventions on mental health and well-being for survivors of rape, sexual assault or sexual abuse experienced during adulthood. SEARCH METHODS: In January 2022, we searched CENTRAL, MEDLINE, Embase, 12 other databases and three trials registers. We also checked reference lists of included studies, contacted authors and experts, and ran forward citation searches. SELECTION CRITERIA: Any study that allocated individuals or clusters of individuals by a random or quasi-random method to a psychosocial intervention that promoted recovery and healing following exposure to rape, sexual assault or sexual abuse in those aged 18 years and above compared with no or minimal intervention, usual care, wait-list, pharmacological only or active comparison(s). We classified psychosocial interventions according to Cochrane Common Mental Disorders Group's psychological therapies list. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. MAIN RESULTS: We included 36 studies (1991 to 2021) with 3992 participants randomly assigned to 60 experimental groups (3014; 76%) and 23 inactive comparator conditions (978, 24%). The experimental groups consisted of: 32 Cognitive Behavioural Therapy (CBT); 10 behavioural interventions; three integrative therapies; three humanist; five other psychologically oriented interventions; and seven other psychosocial interventions. Delivery involved 1 to 20 (median 11) sessions of traditional face-to-face (41) or other individual formats (four); groups (nine); or involved computer-only interaction (six). Most studies were conducted in the USA (n = 26); two were from South Africa; two from the Democratic Republic of the Congo; with single studies from Australia, Canada, the Netherlands, Spain, Sweden and the UK. Five studies did not disclose a funding source, and all disclosed sources were public funding. Participants were invited from a range of settings: from the community, through the media, from universities and in places where people might seek help for their mental health (e.g. war veterans), in the aftermath of sexual trauma (sexual assault centres and emergency departments) or for problems that accompany the experience of sexual violence (e.g. sexual health/primary care clinics). Participants randomised were 99% women (3965 participants) with just 27 men. Half were Black, African or African-American (1889 participants); 40% White/Caucasian (1530 participants); and 10% represented a range of other ethnic backgrounds (396 participants). The weighted mean age was 35.9 years (standard deviation (SD) 9.6). Eighty-two per cent had experienced rape or sexual assault in adulthood (3260/3992). Twenty-two studies (61%) required fulfilling a measured PTSD diagnostic threshold for inclusion; however, 94% of participants (2239/2370) were reported as having clinically relevant PTSD symptoms at entry. The comparison of psychosocial interventions with inactive controls detected that there may be a beneficial effect at post-treatment favouring psychosocial interventions in reducing PTSD (standardised mean difference (SMD) -0.83, 95% confidence interval (CI) -1.22 to -0.44; 16 studies, 1130 participants; low-certainty evidence; large effect size based on Cohen's D); and depression (SMD -0.82, 95% CI -1.17 to -0.48; 12 studies, 901 participants; low-certainty evidence; large effect size). Psychosocial interventions, however, may not increase the risk of dropout from treatment compared to controls, with a risk ratio of 0.85 (95% CI 0.51 to 1.44; 5 studies, 242 participants; low-certainty evidence). Seven of the 23 studies (with 801 participants) comparing a psychosocial intervention to an inactive control reported on adverse events, with 21 events indicated. Psychosocial interventions may not increase the risk of adverse events compared to controls, with a risk ratio of 1.92 (95% CI 0.30 to 12.41; 6 studies; 622 participants; very low-certainty evidence). We conducted an assessment of risk of bias using the RoB 2 tool on a total of 49 reported results. A high risk of bias affected 43% of PTSD results; 59% for depression symptoms; 40% for treatment dropout; and one-third for adverse events. The greatest sources of bias were problems with randomisation and missing outcome data. Heterogeneity was also high, ranging from I2 = 30% (adverse events) to I2 = 87% (PTSD). AUTHORS' CONCLUSIONS: Our review suggests that survivors of rape, sexual violence and sexual abuse during adulthood may experience a large reduction in post-treatment PTSD symptoms and depressive symptoms after experiencing a psychosocial intervention, relative to comparison groups. Psychosocial interventions do not seem to increase dropout from treatment or adverse events/effects compared to controls. However, the number of dropouts and study attrition were generally high, potentially missing harms of exposure to interventions and/or research participation. Also, the differential effects of specific intervention types needs further investigation. We conclude that a range of behavioural and CBT-based interventions may improve the mental health of survivors of rape, sexual assault and sexual abuse in the short term. Therefore, the needs and preferences of individuals must be considered in selecting suitable approaches to therapy and support. The primary outcome in this review focused on the post-treatment period and the question about whether benefits are sustained over time persists. However, attaining such evidence from studies that lack an active comparison may be impractical and even unethical. Thus, we suggest that studies undertake head-to-head comparisons of different intervention types; in particular, of novel, emerging therapies, with one-year plus follow-up periods. Additionally, researchers should focus on the therapeutic benefits and costs for subpopulations such as male survivors and those living with complex PTSD.

Survivor, family and professional experiences of psychosocial interventions for sexual abuse and violence: a qualitative evidence synthesis.

BACKGROUND: It is well-established that experiencing sexual abuse and violence can have a range of detrimental impacts; a wide variety of interventions exist to support survivors in the aftermath. Understanding the experiences and perspectives of survivors receiving such interventions, along with those of their family members, and the professionals who deliver them is important for informing decision making as to what to offer survivors, for developing new interventions, and enhancing their acceptability. OBJECTIVES: This review sought to: 1. identify, appraise and synthesise qualitative studies exploring the experiences of child and adult survivors of sexual abuse and violence, and their caregivers, regarding psychosocial interventions aimed at supporting survivors and preventing negative health outcomes in terms of benefits, risks/harms and barriers; 2. identify, appraise and synthesise qualitative studies exploring the experiences of professionals who deliver psychosocial interventions for sexual abuse and violence in terms of perceived benefits, risks/harms and barriers for survivors and their families/caregivers; 3. develop a conceptual understanding of how different factors influence uptake, dropout or completion, and outcomes from psychosocial interventions for sexual abuse and violence; 4. develop a conceptual understanding of how features and types of interventions responded to the needs of different user/survivor groups (e.g. age groups; types of abuse exposure; migrant populations) and contexts (healthcare/therapeutic settings; low- and middle-income countries (LMICs)); 5. explore how the findings of this review can enhance our understanding of the findings from the linked and related reviews assessing the effectiveness of interventions aimed at supporting survivors and preventing negative health outcomes. SEARCH METHODS: In August 2021 we searched MEDLINE, Embase, PsycINFO and nine other databases. We also searched for unpublished reports and qualitative reports of quantitative studies in a linked systematic review, together with reference checking, citation searches and contacting authors and other researchers to identify relevant studies. SELECTION CRITERIA: We included qualitative and mixed-methods studies (with an identifiable qualitative component) that were linked to a psychosocial intervention aimed at supporting survivors of sexual abuse and violence. Eligible studies focused on at least one of three participant groups: survivors of any age, gender, sexuality, ethnicity or [dis]ability who had received a psychosocial intervention; their carers, family members or partners; and professionals delivering such interventions. We placed no restrictions in respect of settings, locations, intervention delivery formats or durations. DATA COLLECTION AND ANALYSIS: Six review authors independently assessed the titles, abstracts and full texts identified. We extracted data using a form designed for this synthesis, then used this information and an appraisal of data richness and quality in order to stratify the studies using a maximum variation approach. We assessed the methodological limitations using the Critical Skills Appraisal Programme (CASP) tool. We coded directly onto the sampled papers using NVivo and synthesised data using a thematic synthesis methodology and used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We used a narrative synthesis and matrix model to integrate our qualitative evidence synthesis (QES) findings with those of intervention review findings. MAIN RESULTS: We identified 97 eligible studies and sampled 37 of them for our analysis. Most sampled studies were from high-income countries, with four from middle-income and two from low-income countries. In 27 sampled studies, the participants were survivors, in three they were intervention facilitators. Two included all three of our stakeholder groups, and five included two of our groups. The studies explored a wide range of psychosocial interventions, with only one type of intervention explored in more than one study. The review indicates that features associated with the context in which interventions were delivered had an impact on how individuals accessed and experienced interventions. This included organisational features, such as staff turnover, that could influence survivors' engagement with interventions; the setting or location in which interventions were delivered; and the characteristics associated with who delivered the interventions. Studies that assess the effectiveness of interventions typically assess their impact on mental health; however, as well as finding benefits to mental health, our QES found that study participants felt interventions also had positive impacts on their physical health, mood, understanding of trauma, interpersonal relationships and enabled them to re-engage with a wide range of areas in their lives. Participants explained that features of interventions and their contexts that best enabled them to benefit from interventions were also often things that could be a barrier to benefiting from interventions. For example, the relationship with the therapist, when open and warm was a benefit, but if such a relationship could not be achieved, it was a barrier. Survivors' levels of readiness and preparedness to both start and end interventions could have positive (if they were ready) or negative (if they were not) impacts. Study participants identified the potential risks and harms associated with completing interventions but felt that it was important to face and process trauma. Some elements of interventions were specific to the intervention type (e.g. faith-based interventions), or related to an experience of an intervention that held particular relevance to subgroups of survivors (e.g. minority groups); these issues could impact how individuals experienced delivering or receiving interventions. AUTHORS' CONCLUSIONS: We had high or moderate confidence in all but one of our review findings. Further research in low- and middle-income settings, with male survivors of sexual abuse and violence and those from minority groups could strengthen the evidence for low and moderate confidence findings. We found that few interventions had published quantitative and qualitative evaluations. Since this QES has highlighted important aspects that could enable interventions to be more suitable for survivors, using a range of methodologies would provide valuable information that could enhance intervention uptake, completion and effectiveness. This study has shown that although survivors often found interventions difficult, they also appreciated that they needed to work through trauma, which they said resulted in a wide range of benefits. Therefore, listening to survivors and providing appropriate interventions, at the right time for them, can make a significant difference to their health and well-being.

Psychological therapies for women who experience intimate partner violence.

BACKGROUND: Intimate partner violence (IPV) against women is prevalent and strongly associated with mental health problems. Women experiencing IPV attend health services frequently for mental health problems. The World Health Organization recommends that women who have experienced IPV and have a mental health diagnosis should receive evidence-based mental health treatments. However, it is not known if psychological therapies work for women in the context of IPV and whether they cause harm. OBJECTIVES: To assess the effectiveness of psychological therapies for women who experience IPV on the primary outcomes of depression, self-efficacy and an indicator of harm (dropouts) at six- to 12-months' follow-up, and on secondary outcomes of other mental health symptoms, anxiety, quality of life, re-exposure to IPV, safety planning and behaviours, use of healthcare and IPV services, and social support. SEARCH METHODS: We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR), CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, and three other databases, to the end of October 2019. We also searched international trials registries to identify unpublished or ongoing trials and handsearched selected journals, reference lists of included trials and grey literature. SELECTION CRITERIA: We included randomised controlled trials (RCTs), quasi-RCTs, cluster-RCTs and cross-over trials of psychological therapies with women aged 16 years and older who self-reported recent or lifetime experience of IPV. We included trials if women also experienced co-existing mental health diagnoses or substance abuse issues, or both. Psychological therapies included a wide range of interventions that targeted cognition, motivation and behaviour compared with usual care, no treatment, delayed or minimal interventions. We classified psychological therapies according to Cochrane Common Mental Disorders's psychological therapies list. DATA COLLECTION AND ANALYSIS: Two review authors extracted data and undertook 'Risk of Bias' assessment. Treatment effects were compared between experimental and comparator interventions at short-term (up to six months post-baseline), medium-term (six to under 12 months, primary outcome time point), and long-term follow-up (12 months and above). We used standardised mean difference (SMD) for continuous and odds ratio (OR) for dichotomous outcomes, and used random-effects meta-analysis, due to high heterogeneity across trials. MAIN RESULTS: We included 33 psychological trials involving 5517 women randomly assigned to experimental (2798 women, 51%) and comparator interventions (2719 women, 49%). Psychological therapies included 11 integrative therapies, nine humanistic therapies, six cognitive behavioural therapy, four third-wave cognitive behavioural therapies and three other psychologically-orientated interventions. There were no trials classified as psychodynamic therapies. Most trials were from high-income countries (19 in USA, three in Iran, two each in Australia and Greece, and one trial each in China, India, Kenya, Nigeria, Pakistan, Spain and UK), among women recruited from healthcare, community, shelter or refuge settings, or a combination of any or all of these. Psychological therapies were mostly delivered face-to-face (28 trials), but varied by length of treatment (two to 50 sessions) and staff delivering therapies (social workers, nurses, psychologists, community health workers, family doctors, researchers). The average sample size was 82 women (14 to 479), aged 37 years on average, and 66% were unemployed. Half of the women were married or living with a partner and just over half of the participants had experienced IPV in the last 12 months (17 trials), 6% in the past two years (two trials) and 42% during their lifetime (14 trials). Whilst 20 trials (61%) described reliable low-risk random-sampling strategies, only 12 trials (36%) described reliable procedures to conceal the allocation of participant status. While 19 trials measured women's depression, only four trials measured depression as a continuous outcome at medium-term follow-up. These showed a probable beneficial effect of psychological therapies in reducing depression (SMD -0.24, 95% CI -0.47 to -0.01; four trials, 600 women; moderate-certainty evidence). However, for self-efficacy, there may be no evidence of a difference between groups (SMD -0.12, 95% CI -0.33 to 0.09; one trial with medium-term follow-up data, 346 women; low-certainty evidence). Further, there may be no difference between the number of women who dropped out from the experimental or comparator intervention groups, an indicator of no harm (OR 1.04, 95% CI 0.75 to 1.44; five trials with medium-term follow-up data, 840 women; low-certainty evidence). Although no trials reported adverse events from psychological therapies or participation in the trial, only one trial measured harm outcomes using a validated scale. For secondary outcomes, trials measured anxiety only at short-term follow-up, showing that psychological therapies may reduce anxiety symptoms (SMD -0.96, 95% CI -1.29 to -0.63; four trials, 158 women; low-certainty evidence). However, within medium-term follow-up, low-certainty evidence revealed that there may be no evidence between groups for the outcomes safety planning (SMD 0.04, 95% CI -0.18 to 0.25; one trial, 337 women), post-traumatic stress disorder (SMD -0.24, 95% CI -0.54 to 0.06; four trials, 484 women) or re-exposure to any form of IPV (SMD 0.03, 95% CI -0.14 to 0.2; two trials, 547 women). AUTHORS' CONCLUSIONS: There is evidence that for women who experience IPV, psychological therapies probably reduce depression and may reduce anxiety. However, we are uncertain whether psychological therapies improve other outcomes (self-efficacy, post-traumatic stress disorder, re-exposure to IPV, safety planning) and there are limited data on harm. Thus, while psychological therapies probably improve emotional health, it is unclear if women's ongoing needs for safety, support and holistic healing from complex trauma are addressed by this approach. There is a need for more interventions focused on trauma approaches and more rigorous trials (with consistent outcomes at similar follow-up time points), as we were unable to synthesise much of the research.

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.

Screening women for intimate partner violence in healthcare settings.

BACKGROUND: Intimate partner violence (IPV) damages individuals, their children, communities, and the wider economic and social fabric of society. Some governments and professional organisations recommend screening all women for IPV rather than asking only women with symptoms (case-finding). Here, we examine the evidence for whether screening benefits women and has no deleterious effects. OBJECTIVES: To assess the effectiveness of screening for IPV conducted within healthcare settings on identification, referral, re-exposure to violence, and health outcomes for women, and to determine if screening causes any harm. SEARCH METHODS: On 17 February 2015, we searched CENTRAL, Ovid MEDLINE, Embase, CINAHL, six other databases, and two trial registers. We also searched the reference lists of included articles and the websites of relevant organisations. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials assessing the effectiveness of IPV screening where healthcare professionals either directly screened women face-to-face or were informed of the results of screening questionnaires, as compared with usual care (which could include screening that did not involve a healthcare professional). DATA COLLECTION AND ANALYSIS: Two authors independently assessed the risk of bias in the trials and undertook data extraction. For binary outcomes, we calculated a standardised estimation of the odds ratio (OR). For continuous data, either a mean difference (MD) or standardised mean difference (SMD) was calculated. All are presented with a 95% confidence interval (CI). MAIN RESULTS: We included 13 trials that recruited 14,959 women from diverse healthcare settings (antenatal clinics, women's health clinics, emergency departments, primary care) predominantly located in high-income countries and urban settings. The majority of studies minimised selection bias; performance bias was the greatest threat to validity. The overall quality of the body of evidence was low to moderate, mainly due to heterogeneity, risk of bias, and imprecision.We excluded five of 13 studies from the primary analysis as they either did not report identification data, or the way in which they did was not consistent with clinical identification by healthcare providers. In the remaining eight studies (n = 10,074), screening increased clinical identification of victims/survivors (OR 2.95, 95% CI 1.79 to 4.87, moderate quality evidence).Subgroup analyses suggested increases in identification in antenatal care (OR 4.53, 95% CI 1.82 to 11.27, two studies, n = 663, moderate quality evidence); maternal health services (OR 2.36, 95% CI 1.14 to 4.87, one study, n = 829, moderate quality evidence); and emergency departments (OR 2.72, 95% CI 1.03 to 7.19, three studies, n = 2608, moderate quality evidence); but not in hospital-based primary care (OR 1.53, 95% CI 0.79 to 2.94, one study, n = 293, moderate quality evidence).Only two studies (n = 1298) measured referrals to domestic violence support services following clinical identification. We detected no evidence of an effect on referrals (OR 2.24, 95% CI 0.64 to 7.86, low quality evidence).Four of 13 studies (n = 2765) investigated prevalence (excluded from main analysis as rates were not clinically recorded); detection of IPV did not differ between face-to-face screening and computer/written-based assessment (OR 1.12, 95% CI 0.53 to 2.36, moderate quality evidence).Only two studies measured women's experience of violence (three to 18 months after screening) and found no evidence that screening decreased IPV.Only one study reported on women's health with no differences observable at 18 months.Although no study reported adverse effects from screening interventions, harm outcomes were only measured immediately afterwards and only one study reported outcomes at three months.There was insufficient evidence on which to judge whether screening increases uptake of specialist services, and no studies included an economic evaluation. AUTHORS' CONCLUSIONS: The evidence shows that screening increases the identification of women experiencing IPV in healthcare settings. Overall, however, rates were low relative to best estimates of prevalence of IPV in women seeking healthcare. Pregnant women in antenatal settings may be more likely to disclose IPV when screened, however, rigorous research is needed to confirm this. There was no evidence of an effect for other outcomes (referral, re-exposure to violence, health measures, lack of harm arising from screening). Thus, while screening increases identification, there is insufficient evidence to justify screening in healthcare settings. Furthermore, there remains a need for studies comparing universal screening to case-finding (with or without advocacy or therapeutic interventions) for women's long-term wellbeing in order to inform IPV identification policies in healthcare settings.

SEQUenCE: a service user-centred quality of care instrument for mental health services.

OBJECTIVE: To develop a quality of care instrument that is grounded in the service user perspective and validate it in a mental health service. DESIGN: The instrument (SEQUenCE (SErvice user QUality of CarE)) was developed through analysis of focus group data and clinical practice guidelines, and refined through field-testing and psychometric analyses. SETTING: All participants were attending an independent mental health service in Ireland. PARTICIPANTS: Participants had a diagnosis of bipolar affective disorder (BPAD) or a psychotic disorder. INTERVENTIONS: Twenty-nine service users participated in six focus group interviews. Seventy-one service users participated in field-testing: 10 judged the face validity of an initial 61-item instrument; 28 completed a revised 52-item instrument from which 12 items were removed following test-retest and convergent validity analyses; 33 completed the resulting 40-item instrument. MAIN OUTCOME MEASURES: Test-retest reliability, internal consistency and convergent validity of the instrument. RESULTS: The final instrument showed acceptable test-retest reliability at 5-7 days (r = 0.65; P < 0.001), good convergent validity with the Verona Service Satisfaction Scale (r = 0.84, P < 0.001) and good internal consistency (Cronbach's alpha = 0.87). CONCLUSIONS: SEQUenCE is a valid, reliable scale that is grounded in the service user perspective and suitable for routine use. It may serve as a useful tool in individual care planning, service evaluation and research. The instrument was developed and validated with service users with a diagnosis of either BPAD or a psychotic disorder; it does not yet have established external validity for other diagnostic groups.

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.

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.

Screening women for intimate partner violence in healthcare settings.

BACKGROUND: Intimate partner violence (IPV) damages individuals, their children, communities, and the wider economic and social fabric of society. Some governments and professional organisations recommend screening all women for intimate partner violence rather than asking only women with symptoms (case-finding); however, what is the evidence that screening interventions will increase identification, and referral to support agencies, or improve women's subsequent wellbeing and not cause harm? OBJECTIVES: To assess the effectiveness of screening for intimate partner violence conducted within healthcare settings for identification, referral to support agencies and health outcomes for women. SEARCH METHODS: We searched the following databases in July 2012: CENTRAL (2012, Issue 6), MEDLINE (1948 to September Week June Week 3 2012), EMBASE (1980 to Week 28 2012), MEDLINE In-Process (3 July 2012), DARE (2012, Issue 2), CINAHL (1937 to current), PsycINFO (1806 to June Week 4 2012), Sociological Abstracts (1952 to current) and ASSIA (1987 to October 2010). In addition we searched the following trials registers: metaRegister of Controlled Trials (mRCT) (to July 2012), and International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov, Australian New Zealand Clinical Trials Registry and the International Standard Randomised Controlled Trial Number Register to August 2010. We also searched the reference lists of articles and websites of relevant organisations. SELECTION CRITERIA: Randomised or quasi-randomised trials assessing the effectiveness of IPV screening where healthcare professionals screened women face-to-face or were informed of results of screening questionnaires, compared with usual care ( which included screening for other purposes). DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the risk of bias in the trials and undertook data extraction. For binary outcomes, we calculated a standardised estimation of the risk ratio (RR) and for continuous data, either a mean difference (MD) or standardised mean difference (SMD). All are presented with a 95% confidence interval (CI). MAIN RESULTS: We included 11 trials that recruited 13,027 women overall. Six of 10 studies were assessed as being at high risk of bias.When data from six comparable studies were combined (n = 3564), screening increased identification of victims/survivors (RR 2.33; 95% CI 1.40 to 3.89), particularly in antenatal settings (RR 4.26; 95% CI 1.76 to 10.31).Only three studies measured referrals to support agencies (n = 1400). There is no evidence that screening increases such referrals, as although referral numbers increased in the screened group, actual numbers were very small and crossed the line of no effect (RR 2.67; 95% CI 0.99 to 7.20).Only two studies measured women's experience of violence after screening (one at three months, the other at six, 12 and 18 months after screening) and found no significant reduction of abuse.Only one study measured adverse effects and data from this study suggested that screening may not cause harm. This same study showed a trend towards mental health benefit, but the results did not reach statistical significance.There was insufficient evidence on which to judge whether screening increases take up of specialist services, and no studies included economic evaluation. AUTHORS' CONCLUSIONS: Screening is likely to increase identification rates but rates of referral to support agencies are low and as yet we know little about the proportions of false measurement (negatives or positives). Screening does not appear to cause harm, but only one study examined this outcome. As there is an absence of evidence of long-term benefit for women, there is insufficient evidence to justify universal screening in healthcare settings. Studies comparing screening versus case finding (with or without advocacy or therapeutic interventions) for women's long-term wellbeing would better inform future policies in healthcare settings.

GPs' communication skills - a study into women's comfort to disclose intimate partner violence.

BACKGROUND: Quantitative research investigating the effects of general practitioner communication on a patient's comfort to disclose intimate partner violence is lacking. We explored the association between GPs' communication and patients' comfort to discuss fear of an intimate partner. METHODS: A health/lifestyle survey mailed to 14 031 women (aged 16-50 years) who attended the participating GPs of 40 Victorian general practices during the previous year. RESULTS: There was a 32% response rate (n=4467). The results showed that female GPs were perceived as having better communication; an association between female GPs and comfort to disclose was not apparent in multivariate analyses. Time, caring, involving the patient in decisions and putting the patient at ease maintained associations with comfort to discuss, as did language, lower education, age >25 years and current fear. DISCUSSION: This study advocates increasing communication competence to allow for greater disclosure of sensitive issues such as intimate partner violence in the primary care context. However, it also signals a need in research and practice to focus on marginalised groups and intimate partner violence.

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 women's 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.

Multi-disciplinary Evaluation of Sexual Assault Referral Centres (SARCs) for better Health (MESARCH): protocol for a 1-year cohort study examining health, well-being and cost outcomes in adult survivors of sexual assault attending SARCs in England.

INTRODUCTION: Sexual violence is commonplace and has serious adverse consequences for physical and mental health. Sexual Assault Referral Centres (SARCs) are viewed as a best practice response. Little is known about their effectiveness and cost-effectiveness. Long-term data on the health and well-being of those who have experienced rape and sexual assault are also lacking. METHODS AND ANALYSIS: This is a mixed-methods protocol for a 1-year cohort study aiming to examine the health and well-being in survivors of sexual violence after attending a SARC in England. Quantitative measures are being taken at baseline, 6 and 12 months. Post-traumatic stress (PTS) is the primary outcome (target N=270 at 12-month follow-up). Secondary measures include anxiety, depression, substance use and sexual health and well-being. Using mixed-effects regression, our main analysis will examine whether variation in SARC service delivery and subsequent mental healthcare is associated with improvement in trauma symptoms after 12 months. An economic analysis will compare costs and outcomes associated with different organisational aspects of SARC service delivery and levels of satisfaction with care. A nested qualitative study will employ narrative analysis of transcribed interviews with 30 cohort participants and 20 survivors who have not experienced SARC services. ETHICS AND DISSEMINATION: The research is supported by an independent study steering committee, data monitoring and ethics committee and patient and public involvement (PPI) group. A central guiding principle of the research is that being involved should feel diametrically opposed to being a victim of sexual violence, and be experienced as empowering and supportive. Our PPI representatives are instrumental in this, and our wider stakeholders encourage us to consider the health and well-being of all involved. We will disseminate widely through peer-reviewed articles and non-academic channels to maximise the impact of findings on commissioning of services and support for survivors. TRIAL REGISTRATION NUMBER: ISRCTN30846825.

Intimate partner violence - identification and response in general practice.

BACKGROUND: Intimate partner violence is a common problem among women attending general practice, with around one in 10 women currently experiencing physical, sexual or emotional abuse by a partner. Abused women frequently present with physical and psychosocial issues. Yet intimate partner violence often remains concealed and addressing it poses challenges for the clinician and patient alike. OBJECTIVE: Although some of the general recommendations in this review may also apply to same-sex relationships and to women who abuse men, this article discusses identifying intimate partner violence in women who present to general practice. DISCUSSION: Identifying intimate partner violence is important in clinical practice as it underlies many common physical and mental health presentations. Facilitating disclosure and responding effectively requires good communication skills. Safety assessment of women and their families, pinpointing level of readiness to contemplate action, and providing appropriate referral options and ongoing nonjudgmental support are elements of an effective response. General practitioners have the potential to identify women and support them safely on a pathway to recovery, thereby avoiding the long term impacts of intimate partner violence.

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

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.

Women's evaluation of abuse and violence care in general practice: a cluster randomised controlled trial (weave).

BACKGROUND: Intimate partner abuse (IPA) is a major public health problem with serious implications for the physical and psychosocial wellbeing of women, particularly women of child-bearing age. It is a common, hidden problem in general practice and has been under-researched in this setting. Opportunities for early intervention and support in primary care need to be investigated given the frequency of contact women have with general practice. Despite the high prevalence and health consequences of abuse, there is insufficient evidence for screening in primary care settings. Furthermore, there is little rigorous evidence to guide general practitioners (GPs) in responding to women identified as experiencing partner abuse. This paper describes the design of a trial of a general practice-based intervention consisting of screening for fear of partner with feedback to GPs, training for GPs, brief counselling for women and minimal practice organisational change. It examines the effect on women's quality of life, mental health and safety behaviours. METHODS/DESIGN: weave is a cluster randomised controlled trial involving 40 general practices in Victoria, Australia. Approximately 500 women (16-50 years) seen by the GP in the previous year are mailed a short lifestyle survey containing an item to screen for IPA. Women who indicate that they were afraid of a partner/ex-partner in the last year and provide contact details are invited to participate. Once baseline data are collected, GPs are randomly assigned to either a group involving healthy relationship and responding to IPA training plus inviting women for up to 6 sessions of counselling or to a group involving basic education and usual care for women. Outcomes will be evaluated by postal survey at 6 and 12 months following delivery of the intervention. There will be an economic evaluation, and process evaluation involving interviews with women and GPs, to inform understanding about implementation and outcomes. DISCUSSION: The weave trial responds to an urgent need for more evidence on what can be achieved in primary care with regard to responding to women who experience IPA. It will provide important knowledge about the effectiveness of a brief method of screening, professional IPA training program and brief counselling for women. TRIAL REGISTRATION: [ACTRN12608000032358].

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.

Women's experiences and expectations after disclosure of intimate partner abuse to a healthcare provider: A qualitative meta-synthesis.

OBJECTIVE: To identify and synthesise the experiences and expectations of women victim/survivors of intimate partner abuse (IPA) following disclosure to a healthcare provider (HCP). METHODS: The databases MEDLINE, Embase, CINAHL, PsychINFO, SocINDEX, ASSIA and the Cochrane Library were searched in February 2020. Included studies needed to focus on women's experiences with and expectations of HCPs after disclosure of IPA. We considered primary studies using qualitative methods for both data collection and analysis published since 2004. Studies conducted in any country, in any type of healthcare setting, were included. The quality of individual studies was assessed using an adaptation of the Critical Appraisal Skills Programme checklist for qualitative studies. The confidence in the overall evidence base was determined using Grading of Recommendations, Assessment, Development and Evaluations (GRADE)-Confidence in the Evidence from Reviews of Qualitative Research methods. Thematic synthesis was used for analysis. RESULTS: Thirty-one papers describing 30 studies were included in the final review. These were conducted in a range of health settings, predominantly in the USA and other high-income countries. All studies were in English. Four main themes were developed through the analysis, describing women's experiences and expectations of HCPs: (1) connection through kindness and care; (2) see the evil, hear the evil, speak the evil; (3) do more than just listen; and (4) plant the right seed. If these key expectations were absent from care, it resulted in a range of negative emotional impacts for women. CONCLUSIONS: Our findings strongly align with the principles of woman-centred care, indicating that women value emotional connection, practical support through action and advocacy and an approach that recognises their autonomy and is tailored to their individual needs. Drawing on the evidence, we have developed a best practice model to guide practitioners in how to deliver woman-centred care. This review has critical implications for practice, highlighting the simplicity of what HCPs can do to support women experiencing IPA, although its applicability to low-income and-middle income settings remains to be explored.

Acute shoulder pain in primary care - an observational study.

BACKGROUND: Shoulder pain is a common presentation in general practice. Data on prognosis, treatment and compliance for acute shoulder pain are lacking but would be valuable for guiding decision making. This study collected data on acute shoulder pain and its outcome over 6 months. METHODS: A prospective observational study of 100 acute shoulder pain patients from 21 general practices in southeast Queensland. RESULTS: Disability levels at presentation were the best predictor of outcome at 6 months. Patients who had not fully recovered at 6 months had higher risk of depression at presentation. The biggest improvements in pain and disability scores occurred in the first month of management, with almost 60% of patients fully recovered at 6 months. Over 40% of patients had at least one radiological investigation for their pain. DISCUSSION: Measuring disability, pain and mood levels in acute shoulder pain patients gives the best prognostic data. The use of radiological investigations may be higher than is clinically necessary. Early multimodal management of acute shoulder pain patients needs consideration.

Identifying unmet needs in older patients--nurse-GP collaboration in general practice.

BACKGROUND: Australia's rapidly aging population has a high prevalence of chronic disease and disability, leading to an increased social and economic burden. The Enhanced Primary Care program seeks to reduce this burden by promoting preventive and coordinated care. This study aimed to identify unmet needs in community dwelling general practice patients aged 75 years and over through annual health assessments performed by a general practitioner-nurse team. METHODS: Community dwelling patients of a large suburban general practice aged 75 years and over were invited to participate. Five hundred and forty-six consecutive, eligible patients were recruited. Data were collected by GP-nurse teams on physical and psychosocial variables using a combination of physical examination, self reporting, and rating scales. RESULTS: Fifty percent of the women and 25% of the men lived alone. Over 90% of participants reported one or more health problems, with musculoskeletal issues being most common. Men rated their health more poorly than women. Incontinence affected one-third of patients, mainly women. Women reported more psychological distress. There were age and gender differences in activities of daily living (ADL). Mobility, ADL, visual impairment, bowel problems, use of sleep medications and psychological wellbeing were strongly associated to self reported health. DISCUSSION: Health assessments were effective in identifying significant physical and psychosocial problems in older adults. The importance of such assessments is underscored by strong associations between various domains and perceived general health. Collaboration between a GP and a practice based community nurse represents a potential solution to identifying (and responding to) unmet physical and psychosocial needs to improve quality of life in community dwelling older adults.