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Cochrane Database of Systematic Reviews

Advocacy interventions to reduce or eliminate violence and


promote the physical and psychosocial well-being of women
who experience intimate partner abuse (Review)

Rivas C, Ramsay J, Sadowski L, Davidson LL, Dunne D, Eldridge S, Hegarty K, Taft A, Feder G

Rivas C, Ramsay J, Sadowski L, Davidson LL, Dunne D, Eldridge S, Hegarty K, Taft A, Feder G.
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 2015, Issue 12. Art. No.: CD005043.
DOI: 10.1002/14651858.CD005043.pub3.

www.cochranelibrary.com

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS

HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . . 5
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
ADDITIONAL SUMMARY OF FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . 34
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Figure 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Figure 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Analysis 1.1. Comparison 1 Physical abuse, Outcome 1 Brief advocacy. . . . . . . . . . . . . . . . . 104
Analysis 1.2. Comparison 1 Physical abuse, Outcome 2 Brief advocacy (dichotomous outcome) (up to 12 months follow-
up). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Analysis 1.3. Comparison 1 Physical abuse, Outcome 3 Brief advocacy (mean change). . . . . . . . . . . . 105
Analysis 1.4. Comparison 1 Physical abuse, Outcome 4 Intensive advocacy. . . . . . . . . . . . . . . . 106
Analysis 1.5. Comparison 1 Physical abuse, Outcome 5 Intensive advocacy (dichotomous outcome). . . . . . . 107
Analysis 1.6. Comparison 1 Physical abuse, Outcome 6 Intensive advocacy: missing reassigned (dichotomous outcome) (up
to 12 months follow-up). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Analysis 1.7. Comparison 1 Physical abuse, Outcome 7 Any advocacy. . . . . . . . . . . . . . . . . 109
Analysis 1.8. Comparison 1 Physical abuse, Outcome 8 Any advocacy (dichotomous outcome) (up to 12 months follow-
up). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Analysis 2.1. Comparison 2 Sexual abuse, Outcome 1 Brief advocacy (up to 12 months follow-up). . . . . . . 111
Analysis 2.2. Comparison 2 Sexual abuse, Outcome 2 Brief advocacy (mean change) (up to 12 months follow-up). . 111
Analysis 2.3. Comparison 2 Sexual abuse, Outcome 3 Brief advocacy (dichotomous outcome) (up to 12 months follow-
up). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Analysis 3.1. Comparison 3 Emotional abuse, Outcome 1 Brief advocacy. . . . . . . . . . . . . . . . 112
Analysis 3.2. Comparison 3 Emotional abuse, Outcome 2 Brief advocacy (mean change) (up to 12 months follow-up). 113
Analysis 3.3. Comparison 3 Emotional abuse, Outcome 3 Intensive advocacy. . . . . . . . . . . . . . . 114
Analysis 3.4. Comparison 3 Emotional abuse, Outcome 4 Intensive advocacy (dichotomous outcome) (up to 12 months
follow-up). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Analysis 3.5. Comparison 3 Emotional abuse, Outcome 5 Any advocacy. . . . . . . . . . . . . . . . 115
Analysis 4.1. Comparison 4 Risk of homicide, Outcome 1 Brief advocacy. . . . . . . . . . . . . . . . 116
Analysis 5.1. Comparison 5 Risk of work harassment, Outcome 1 Brief advocacy. . . . . . . . . . . . . 117
Analysis 6.1. Comparison 6 Overall abuse, Outcome 1 Brief advocacy (up to 12 months follow-up). . . . . . . 117
Analysis 6.2. Comparison 6 Overall abuse, Outcome 2 Intensive advocacy (up to 12 months follow-up). . . . . . 118
Analysis 6.3. Comparison 6 Overall abuse, Outcome 3 Intensive advocacy (dichotomous outcome) (up to 12 months
follow-up). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Analysis 6.4. Comparison 6 Overall abuse, Outcome 4 Any advocacy (up to 12 months follow-up). . . . . . . 119
Analysis 7.1. Comparison 7 Quality of life, Outcome 1 Brief advocacy: 2 summary component subscales. . . . . 120
Analysis 7.2. Comparison 7 Quality of life, Outcome 2 Brief advocacy: 8 subscales (mean change). . . . . . . . 121
Analysis 7.3. Comparison 7 Quality of life, Outcome 3 Intensive advocacy: 2 summary component subscales. . . . 123
Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience i
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 7.4. Comparison 7 Quality of life, Outcome 4 Intensive advocacy: overall. . . . . . . . . . . . . 124
Analysis 7.5. Comparison 7 Quality of life, Outcome 5 Any advocacy: 2 summary component subscales. . . . . 125
Analysis 8.1. Comparison 8 Depression, Outcome 1 Brief advocacy (up to 12 months follow-up). . . . . . . . 126
Analysis 8.2. Comparison 8 Depression, Outcome 2 Brief advocacy (dichotomous outcome) (up to 12 months follow-
up). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Analysis 8.3. Comparison 8 Depression, Outcome 3 Intensive advocacy. . . . . . . . . . . . . . . . . 128
Analysis 8.4. Comparison 8 Depression, Outcome 4 Intensive advocacy (dichotomous outcome) (up to 12 months follow-
up). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Analysis 8.5. Comparison 8 Depression, Outcome 5 Any advocacy (up to 12 months follow-up). . . . . . . . 129
Analysis 8.6. Comparison 8 Depression, Outcome 6 Any advocacy (dichotomous outcome) (up to 12 months follow-
up). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Analysis 9.1. Comparison 9 Anxiety, Outcome 1 Brief advocacy (up to 12 months follow-up). . . . . . . . . 131
Analysis 9.2. Comparison 9 Anxiety, Outcome 2 Intensive advocacy. . . . . . . . . . . . . . . . . . 131
Analysis 9.3. Comparison 9 Anxiety, Outcome 3 Intensive advocacy (mean change) (up to 12 months follow-up). . 132
Analysis 9.4. Comparison 9 Anxiety, Outcome 4 Any advocacy (up to 12 months follow-up). . . . . . . . . 133
Analysis 10.1. Comparison 10 Chronic pain, Outcome 1 Brief advocacy (up to 12 months follow-up). . . . . . 133
Analysis 11.1. Comparison 11 Chronic fatigue, Outcome 1 Brief advocacy (up to 12 months follow-up). . . . . 134
Analysis 12.1. Comparison 12 Low birth weight, Outcome 1 Brief advocacy (dichotomous outcome). . . . . . 134
Analysis 13.1. Comparison 13 Birth weight (grams), Outcome 1 Brief advocacy. . . . . . . . . . . . . . 135
Analysis 14.1. Comparison 14 Pre-term birth, Outcome 1 Brief advocacy (dichotomous outcome). . . . . . . 135
Analysis 15.1. Comparison 15 Gestational age (weeks) at delivery, Outcome 1 Brief advocacy. . . . . . . . . 136
Analysis 16.1. Comparison 16 Post-traumatic stress, Outcome 1 Brief advocacy (up to 12 months follow-up). . . . 136
Analysis 17.1. Comparison 17 Perception of stress, Outcome 1 Brief advocacy (up to 12 months follow-up). . . . 137
Analysis 18.1. Comparison 18 Self efficacy, Outcome 1 Intensive advocacy. . . . . . . . . . . . . . . . 137
Analysis 19.1. Comparison 19 Self esteem, Outcome 1 Intensive advocacy (up to 12 months follow-up). . . . . . 138
Analysis 20.1. Comparison 20 Perceived social support, Outcome 1 Brief advocacy (up to 12 months follow-up). . . 138
Analysis 20.2. Comparison 20 Perceived social support, Outcome 2 Intensive advocacy. . . . . . . . . . . 139
Analysis 20.3. Comparison 20 Perceived social support, Outcome 3 Intensive advocacy (mean change). . . . . . 140
Analysis 20.4. Comparison 20 Perceived social support, Outcome 4 Any advocacy (up to 12 months follow-up). . . 141
Analysis 21.1. Comparison 21 Independence from abuser, Outcome 1 Intensive advocacy (dichotomous outcome). . 142
Analysis 21.2. Comparison 21 Independence from abuser, Outcome 2 Intensive advocacy: missing reassigned (up to 12
months follow-up) (dichotomous outcome). . . . . . . . . . . . . . . . . . . . . . . . 143
Analysis 22.1. Comparison 22 Emotional attachment to abuser, Outcome 1 Intensive advocacy. . . . . . . . . 144
Analysis 23.1. Comparison 23 Use of safety behaviours, Outcome 1 Brief advocacy. . . . . . . . . . . . . 145
Analysis 24.1. Comparison 24 Use of resources, Outcome 1 Brief advocacy. . . . . . . . . . . . . . . . 146
Analysis 25.1. Comparison 25 Difficulty obtaining resources, Outcome 1 Intensive advocacy. . . . . . . . . 147
ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . . 169
NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience ii
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]

Advocacy interventions to reduce or eliminate violence and


promote the physical and psychosocial well-being of women
who experience intimate partner abuse

Carol Rivas1 , Jean Ramsay2 , Laura Sadowski3 , Leslie L Davidson4 , Danielle Dunne5 , Sandra Eldridge2 , Kelsey Hegarty6 , Angela Taft
7
, Gene Feder8
1 Faculty of Health Sciences, University of Southampton, Southampton, UK. 2 Centre for Primary Care and Public Health, Barts and
The London School of Medicine and Dentistry, Queen Mary University of London, London, UK. 3 Department of Medicine, Stroger
Hospital of Cook County, Chicago, MI, USA. 4 Department of Epidemiology, Mailman School of Public Health, Columbia University,
New York, NY, USA. 5 Evaluation Department, Department for International Development, London, UK. 6 Department of General
Practice, The University of Melbourne, Melbourne, Australia. 7 The Judith Lumley Centre, La Trobe University, Melbourne, Australia.
8
Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK

Contact address: Gene Feder, Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol,
Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK. gene.feder@bristol.ac.uk.

Editorial group: Cochrane Developmental, Psychosocial and Learning Problems Group.


Publication status and date: New search for studies and content updated (no change to conclusions), published in Issue 12, 2015.

Citation: Rivas C, Ramsay J, Sadowski L, Davidson LL, Dunne D, Eldridge S, Hegarty K, Taft A, Feder G. 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 2015, Issue 12. Art. No.: CD005043. DOI: 10.1002/14651858.CD005043.pub3.

Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT
Background
Intimate partner abuse is common worldwide, damaging the short- and long-term physical, mental, and emotional health of survivors
and children. Advocacy may contribute to reducing abuse, empowering women to improve their situation by providing informal
counselling and support for safety planning and increasing access to different services. Advocacy may be a stand-alone service, accepting
referrals from healthcare providers, or part of a multi-component (and possibly multi-agency) intervention provided by service staff or
others.
Objectives
To assess the effects of advocacy interventions within or outside healthcare settings in women who have experienced intimate partner
abuse.
Search methods
In April 2015, we searched CENTRAL, Ovid MEDLINE, EMBASE, and 10 other databases. We also searched WHO ICTRP, mRCT,
and UK Clinical Research Network (UKCRN), and examined relevant websites and reference lists with forward citation tracking of
included studies. For the original review we handsearched six key journals. We also contacted first authors of eligible papers and experts
in the field.
Selection criteria
Randomised or quasi-randomised controlled trials comparing advocacy interventions for women with experience of intimate partner
abuse versus no intervention or usual care (if advocacy was minimal and fewer than 20% of women received it).
Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 1
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Data collection and analysis
Two review authors independently assessed risk of bias and undertook data extraction. We contacted authors for missing information
needed to calculate statistics for the review and looked for adverse events.
Main results
We included 13 trials involving 2141 participants aged 15 to 65 years, frequently having low socioeconomic status.
The studies were quite heterogeneous in terms of methodology, study processes and design, including with regard to the duration of
follow-up (postintervention to three years), although this was not associated with differences in effect. The studies also had considerable
clinical heterogeneity in relation to staff delivering advocacy; setting (community, shelter, antenatal, healthcare); advocacy intensity
(from 30 minutes to 80 hours); and abuse severity. Three trials evaluated advocacy within multi-component interventions. Eleven
measured some form of abuse (eight scales), six assessed quality of life (three scales), and six measured depression (three scales). Countries
and ethnic groups varied (one or more minority ethnic groups in the USA or UK, and local populations in Hong Kong and Peru).
Setting was associated with intensity and duration of advocacy.
Risk of bias was high in five studies, moderate in five, and low in three. The quality of evidence (considering multiple factors such as
risk of bias, study size, missing data) was moderate to low for brief advocacy and very low for intensive advocacy.
Incidence of abuse
Physical abuse
Moderate quality pooled data from two healthcare studies (moderate risk of bias) and one community study (low risk of bias), all
with 12-month follow-up data, showed no effect on physical abuse for brief (< 12 hours) advocacy interventions (standardised mean
difference (SMD) 0.00, 95% confidence interval (CI) - 0.17 to 0.16; n = 558). One antenatal study (low risk of bias) showed an
association between brief advocacy and reduced minor physical abuse at one year (mean difference (MD) change - 1.00, 95% CI -
1.82 to - 0.18; n = 110). An antenatal, multi-component study showed a greater likelihood of physical abuse ending (odds ratio (OR)
0.42, 95% CI 0.23 to 0.75) immediately after advocacy (number needed to treat (NNT) = 8); we cannot exclude impact from other
components.
Low to very low quality evidence from two intensive advocacy trials (12 hours plus duration) showed reduced severe physical abuse in
women leaving a shelter at 24 months (OR 0.39, 95% CI 0.20 to 0.77; NNT = 8), but not at 12 or 36 months.
Sexual abuse
Meta-analysis of two studies (n = 239) showed no effect of advocacy on sexual abuse (SMD - 0.12, 95% CI - 0.37 to 0.14), agreeing
with the change score (MD - 0.07, 95% CI - 0.30 to 0.16) from a third study and the OR (0.96, 95% CI 0.44 to 2.12) from a fourth
antenatal, multi-component study.
Emotional abuse
One study in antenatal care, rated at low risk of bias, showed reduced emotional abuse at ≤ 12-month follow-up (MD (change score)
- 4.24, 95% CI - 6.42 to - 2.06; n = 110).
Psychosocial health
Quality of life
Meta-analysis of two studies (high risk of bias) showed intensive advocacy slightly improved overall quality of life of women recruited
from shelters (MD 0.23, 95% CI 0.00 to 0.46; n = 343) at 12-month follow-up, with greater improvement in perceived physical
quality of life from a primary care study (high risk of bias; MD 4.90, 95% CI 0.98 to 8.82) immediately postintervention.
Depression
Meta-analysis of two studies in healthcare settings, one at high risk of bias and one at moderate risk, showed that fewer women developed
depression (OR 0.31, 95% CI 0.15 to 0.65; n = 149; NNT = 4) with brief advocacy. One study at high risk of bias reported a slight
reduction in depression in pregnant women immediately after the intervention (OR 0.51, 95% CI 0.20 to 1.29; n = 103; NNT = 8).
There was no evidence that intensive advocacy reduced depression at ≤ 12-month follow-up (MD - 0.14, 95% CI - 0.33 to 0.05; 3
studies; n = 446) or at two years (SMD − 0.12, 95% CI − 0.36 to 0.12; 1 study; n = 265).
Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 2
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Adverse effects
Two women died, one who was murdered by her partner and one who committed suicide. No evidence links either death to study
participation.
Authors’ conclusions
Results suggest some benefits from advocacy. However, most studies were underpowered. Clinical and methodological heterogeneity
largely precluded pooling of trials. Therefore, there is uncertainty about the magnitude of benefit, the impact of abuse severity, and the
setting.
Based on the evidence reviewed, intensive advocacy may improve short-term quality of life and reduce physical abuse one to two years
after the intervention for women recruited from domestic violence shelters or refuges. Brief advocacy may provide small short-term
mental health benefits and reduce abuse, particularly in pregnant women and for less severe abuse.

PLAIN LANGUAGE SUMMARY


Advocacy interventions to help women who experience intimate partner abuse to access community resources
Background
Partner abuse (domestic violence) is common worldwide. It includes physical, emotional, and sexual abuse; threats; withholding money;
causing injury; and long-lasting physical and emotional health problems. Advocacy (active support by trained people) may help women
make safety plans, deal with abuse, and access community resources.
Evidence on the effects of advocacy will help service planning and provision.
Method
We searched scientific literature worldwide up to April 2015 for clinical trials comparing advocacy for abused women with no care or
usual care, to understand whether advocacy was safe and effective. We found 13 trials conducted in several countries, involving 2141
women from various ethnic groups, aged 15 to 65 years and often poor.
Studies varied in terms of advocacy duration (30 minutes to 80 hours) and participating staff (students, nurses, professional advocates,
psychologists, social workers, community health workers, mothers in antenatal clinics, researchers). Eleven measured abuse, six assessed
quality of life, and six measured depression. Three considered advocacy plus psychiatric help. Most studies followed up on the women
for at least a year.
Studies recruited women from healthcare settings, domestic violence refuges/shelters, and community centres. Brief advocacy (up to
12 hours) was most common in healthcare settings, and intensive advocacy (more than 12 hours) was more common in other settings.
Key outcomes
Quality of the evidence
Five studies had design flaws that entailed a high risk of biasing their results, while five had moderate risk and three studies had low
risk.
Physical abuse
After one year, brief advocacy had no effect in two healthcare studies of moderate quality or in one community study at low risk of
bias, but it reduced minor abuse in another antenatal care study (low risk of bias). Another antenatal study showed reduced abuse
immediately after brief advocacy (with one woman likely to benefit if eight received the advocacy), but women were also treated for
depression, which may have affected results. Two studies provided weak evidence that intensive advocacy reduces physical abuse up to
two years after the intervention (with one in eight women likely to benefit).
Sexual abuse
Four studies failed to show benefits from advocacy for sexual abuse.
Emotional abuse
Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 3
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
One antenatal care study (low risk of bias) reported reduced emotional abuse at 12 months after advocacy.
Depression
Brief advocacy prevented depression in abused women attending healthcare services and pregnant women immediately after advocacy
(with one woman likely to benefit for every four to eight treated). Intensive advocacy did not reduce depression in shelter women
followed up at 12 and 24 months. The moderate-to-low quality evidence came mostly from studies with a low risk of bias.
Quality of life
Three brief advocacy trials found no benefit on quality of life. Intensive advocacy showed a weak benefit in two studies in domestic
violence shelters/refuges. A primary care study (high risk of bias) showed improved motivation to do daily tasks immediately after
advocacy.
Deaths
Two women died: one was murdered by her partner and one committed suicide; however, investigators did not consider these deaths
to be related to the studies.
Conclusions
Intensive advocacy may improve everyday life for women in domestic violence shelters/refuges in the short term and reduce physical
abuse one to two years after the intervention. There is no clear evidence that intensive advocacy reduces sexual, emotional, or overall
abuse, or that it benefits women’s mental health. It is unclear whether brief advocacy (mostly given in healthcare settings) is effective,
although it may provide short-term mental health benefits and reduce abuse, particularly in pregnant women and those suffering less
severe abuse.
We considered the results of several studies to be potentially biased because of weak study designs. There was little consistency between
studies, with variations in the amount of advocacy given, the type of benefits measured, and the lengths of follow-up periods. As a
result, it was hard to combine their results, and we cannot be certain of how much advocacy interventions benefit women or the impact
of the type of advocacy, the place it was given, or the severity of the abuse experienced by the women receiving the intervention.

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 4
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
intimate partner abuse (Review)
Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation]

Intensive advocacy interventions for women who experience intimate partner abuse versus usual care at up to 12- month follow- up

Patient or population: wom en with intim ate partner abuse


Settings: within or outside of healthcare settings
Intervention: intensive advocacy interventions

Outcomes Illustrative comparative risks* (95% CI) Relative effect No. of participants Quality of the evidence Comments
(95% CI) (studies) (GRADE)

Assumed risk Corresponding risk

Control Intensive advocacy in-


terventions

Physical abuse The m ean physical The m ean physical - 265 ⊕⊕ Sullivan 1992
Conf lict Tactics Scales abuse in the control abuse in the interven- (1 study) Lowa,b,c
(CTS; 80 item s rated on groups was tion groups was 0.12
a 7-point scale) 1 lower (0.39 lower to 0.
Follow-up: 12 m onths 15 higher)

Physical abuse (di- Study population OR 0.61 182 ⊕ Sullivan 1991; Sullivan
chotomous outcome) (0.33 to 1.14) (2 studies) Very lowb,d,e 1992
Follow-up: 12 m onths 453 per 1000 336 per 1000
(215 to 486)

M oderate effect

Emotional abuse (di- Study population OR 0.58 141 ⊕⊕⊕ Sullivan 1992
chotomous outcome) (0.30 to 1.13) (1 study) M oderate e,f
Follow-up: 12 m onths 557 per 1000 422 per 1000
(274 to 587)

M oderate effect
5
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intimate partner abuse (Review)
Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience

Emotional abuse The m ean em otional The m ean em otional - 265 ⊕ Sullivan 1992
Index of Psychologi- abuse in the control abuse in the interven- (1 study) Very lowc,g,h
cal Abuse (IPA; 33 groups was 1.4 tion groups was 0.02
item s rated on a 4-point lower (0.16 lower to 0.
scale) 12 higher)
Follow-up: 12 m onths

Overall abuse The m ean overall abuse The m ean overall abuse - 181 ⊕ Sullivan 2002; Taf t
One study used a com - ranged across control in the intervention (2 studies) Very lowc,,j,k 2011
posite of two scales (12 groups f rom 0.58 to 27. groups was 0.23 stan-
item s. Scale f rom 0 to 10 dard deviations lower
36) (0.53 lower to 0.08
Other study used Com - higher)
posite Abuse Scale
(CAS) i (30 item s pre-
sented in a 6-point
f orm at requiring re-
spondents to answer
’never’, ’only once’, ’sev-
eral tim es’, ’m onthly’,
’weekly’ or ’daily’ in a
12-m onth period)
Follow-up: im m ediately
postintervention to 4
m onths

Overall abuse (di- Study population OR 0.72 103 ⊕ Taf t 2011


chotomous outcome) (0.29 to 1.79) l (1 study) Very lowe,m,n
Follow-up: im m ediately 719 per 1000 648 per 1000 (426 to
postintervention 821)

M oderate effect

* The basis f or the assumed risk (e.g. the m edian control group risk across studies) is provided in f ootnotes. The corresponding risk (and its 95% CI) is based on the assum ed
risk in the com parison group and the relative effect of the intervention (and its 95% CI).
CI: conf idence interval; OR: odds ratio; GRADE: Grades of Recom m endations, Assessm ent, Developm ent, and Evaluation
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Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
intimate partner abuse (Review)
Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience

GRADE Working Group grades of evidence


High quality: Further research is very unlikely to change our conf idence in the estim ate of ef f ect.
M oderate quality: Further research is likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and m ay change the estim ate.
Low quality: Further research is very likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and is likely to change the estim ate.
Very low quality: We are very uncertain about the estim ate.
a Insuf f icientinf orm ation available concerning random sequence generation, blinding and protection against contam ination,
and attrition bias.
b
There is a reduction in ef f ect af ter 24 m onths, which is explained by the authors.
c Sam ple size less than 400.
d One study has incom plete inf orm ation on blinding, but in the other we determ ined that there was no blinding; in addition,

incom plete data on random sequence generation, protection against contam ination and allocation concealm ent, and attrition
bias.
e
Total events less than 300.
f
Result consistent with continuous m easure.
g No blinding and attrition bias; in addition, incom plete data on random sequence generation, protection against contam ination

and allocation concealm ent.


h Result consistent with dichotom ous m easure.
i Com posite of shortened Index of Psychological Abuse (IPA), Conf lict Tactics Scale (CTS), and m odif ied physical violence

subscale (one study), and Com posite Abuse Scale (CAS) (range 0 to 150) (other study).
j One study with very serious bias and one with m any unclear biases and rated as having serious bias.
k Sm all sam ple size (less than 400), standard deviation (SD) greater than 0.5.
l Figures supplied by Taf t f or subset of abused wom en only (paper does not separate abused wom en f rom wom en at risk of

abuse in the analysis).


m Sam ple attrition greater than 20% and dif f erential across groups, not intention-to-treat (ITT), and group allocation not

concealed.
n Wide conf idence intervals around 1.
7
BACKGROUND over their lifetimes (Black 2011; CDC 2008). The prevalence of
intimate partner abuse among women seeking healthcare is higher
than that of the general population (Feder 2009). In a primary
care study, we found a lifetime experience of physical and sexual
Description of the condition
violence of 41%, with 17% of women experiencing such violence
in the past year (Richardson 2002). Abuse of women by their
partners is a global phenomenon, although most studies on it have
Intimate partner abuse
taken place in industrialised countries (Krug 2002; Watts 2002). A
For the purpose of this review, intimate partner abuse (also known WHO study that used standardised population-based household
as domestic violence) is defined as the abuse of a woman by a male surveys showed a lifetime prevalence of physical or sexual intimate
or female partner who currently is, or formerly was, in an intimate partner abuse of 15% to 71% in 10 low- and middle-income
relationship with her. Intimate partner abuse perpetrated against countries (Garcia-Moreno 2006), while more recently, WHO
male partners or ex-partners also occurs, but it is not included in 2013a cites a range of 23% to 37% depending on the region of
this review because the outcomes, and possibly the risks for part- the world.
ner violence, are likely to differ by gender. Most abuse with seri-
ous health and other consequences is committed by men against
their female partners (Henwood 2000; Roe 2010). We also include The impact of intimate partner abuse on women’s
abuse perpetrated by ex-partners in the review, since a woman is of- health
ten at greatest risk when she is preparing to leave or has just left her Intimate partner abuse can have short-term and long-term negative
partner (Brownridge 2006). Women who leave violent relation- health consequences for survivors even after the abuse has ended
ships often continue to be abused, sometimes because the partner (Campbell 2002). World Development Reports and statements
pursues them or because they choose to return (Campbell 2003; from the United Nations emphasise that such violence is a signifi-
Campbell 2004; Holt 2013; Mullen 1999; Shalansky 1999). It is cant cause of death and disability on a global scale (Ingram 2005;
estimated that between 65% and 75% of women killed by abusive World Bank 2006), and the WHO highlights violence against
partners are leaving or have already ended the relationship (Wilson women as a priority health issue (Krug 2002).
1993). Intimate partner abuse may take various forms, including On average, two women in England and Wales are killed each week
physical violence (ranging from slaps, punches, and kicks to chok- by their current or former partners. In 2008 to 2009, this cause ac-
ing, armed assault with a weapon, and homicide), sexual violence counted for 53% of all female homicide cases (Smith 2010). In the
(such as forced sex or forced participation in sexual acts), emotion- United States, it is estimated that partner abuse results in approx-
ally abusive behaviours (such as stalking, surveillance, threats of imately 1200 female deaths each year (CDC 2003). Percentages
abuse, threats to remove children from the household, prohibiting may be even higher in less industrialised countries; internationally,
a woman from seeing her family and friends, ongoing belittlement the WHO reports that between 40% and 70% of female murder
or humiliation, and intimidation), economic restrictions (such as victims (depending on the country) were killed by a current or
preventing a woman from working, confiscating her earnings, re- former partner (Krug 2002). Across all countries with available
stricting access to funds), and other controlling behaviours (Watts data, the WHO reports that partner violence is responsible for an
2002). The different forms of abuse often coexist, but they may average of 38% of all homicides of women (WHO 2013a).
also occur in isolation (Hegarty 2006).
Partner abuse may also coexist with other forms of violence within
Physical health of abused women
families, such as child abuse or elder abuse, but such abuse is not
the focus of this review. Intimate partner abuse is one of the most common causes of non-
fatal injury in women (Ellsberg 2008). In the USA, a review esti-
mated that partner abuse to women accounted for 50% of all acute
Prevalence of intimate partner abuse injuries and 21% of all injuries requiring urgent surgery (Guth
The 2010/11 British Crime Survey found that 27% of women in 2000).
England and Wales had some experience with domestic violence Abused women also experience many chronic health problems.
after the age of 16 (Chaplin 2011). Repeat victimisation accounted The most consistent and largest physical health difference between
for three-quarters (73%) of all such incidents. The global figure for abused and non-abused women relates to gynaecological prob-
prevalence of physical or intimate partner abuse reported by the lems (e.g. sexually transmitted diseases (STDs), vaginal bleeding
World Health Organization (WHO) is 30% (WHO 2013a). Data and infection, genital irritation, chronic pelvic pain, and urinary
collected in the United States in 2005 and in 2010 indicate that one tract infections) (Campbell 2002). Population-based studies from
out of every three to four women experience violence by a current the United States show that the likelihood that abused women
or former partner at some point in their life, with 2 million injuries will exhibit these symptoms is three times greater than average
from intimate partner violence each year and nearly 18 million (McCauley 1995). Women with a history of partner abuse are

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 8
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
more likely to have had an induced abortion (WHO 2013a) and likely to be diagnosed for depression or psychosis (Rodriguez 2008;
there is growing recognition that partner violence also increases a Stark 1996), and they often have feelings of low self-esteem and
woman’s risk of contracting HIV, either directly through unpro- hopelessness (Kirkwood 1993). Among Australian women attend-
tected contact with an infected man and indirectly through the ef- ing general practice who have been abused, those who have expe-
fects of prolonged exposure to stress in their social context (Coker rienced combined physical, emotional, and sexual abuse are much
2007; WHO 2013a). Moreover, in a UK study (John 2004), sig- more likely to be diagnosed with depression than women who have
nificantly more abused women complained of lower abdominal only experienced one kind of abuse (Hegarty 2004). Living in a
pain, dysmenorrhoea, dyspareunia, smear abnormalities, cancer violent relationship may exacerbate a predisposition to depression;
worries, and bowel symptoms than did a group of non-abused however, a woman’s first exposure to abuse can also be a causal
women. factor for subsequent depression (Campbell 1999; Silva 1997).
Other conditions include chronic pain (e.g. headaches, back pain), Abused women are nearly four times as likely to suffer from post-
central nervous system symptoms (e.g. fainting and seizures) traumatic stress disorder than non-abused women, and this can be
(Bonomi 2009a; Campbell 2002; Diaz-Olavarrieta 1999), self- directly related to experiencing intimate partner abuse (Golding
reported gastrointestinal symptoms (e.g. loss of appetite, eat- 1999; Silva 1997). There is also evidence that increased suicidal
ing disorders), diagnosed functional gastrointestinal disorders tendencies are associated with abuse (Golding 1999; Leone 2011).
(e.g. irritable bowel syndrome) (Bonomi 2009a; Coker 2000; Other signs of emotional distress associated with intimate partner
Diaz-Olavarrieta 1999), and self-reported cardiovascular symp- abuse are self harm and parasuicide (Heath 2003; Stark 1996),
toms (e.g. hypertension, chest pain) (Coker 2002; Tollestrup sleep disturbances (Pigeon 2011; Ratner 1993), chronic fatigue
1999). (Cerulli 2011), and anxiety disorders (Cerulli 2011; Ratner 1993).
A Nicaraguan study reported that 70% of cases of emotional dis-
tress in women were a direct consequence of abuse (Ellsberg 1999).
Health of abused women during pregnancy
In industrialised countries, a further mental health problem as-
Research evidence shows that intimate partner abuse continues sociated with partner violence is the abuse of alcohol and drugs
when a woman becomes pregnant (Silva 2011); indeed, it may (Golding 1999; Graham 2011; McCauley 1995; Schumacher
even escalate (Gazmararian 2000; Mezey 1997). Campbell 2002 2012). Substance abuse and intimate partner abuse often occur si-
shows that prevalence rates of abuse during pregnancy are very multaneously. Women who have experienced physical or psycho-
similar in industrialised and non-industrialised countries. logical violence are 15 times more likely to abuse alcohol and 9
The health risks for abused mothers and their unborn children times more likely to abuse drugs than non-abused women (Stark
are substantial. The most serious outcome is the death of the 1996). There is also evidence that alcohol and drug abuse in some
mother (El Kady 2005; Parsons 1999) or the foetus (El Kady 2005; women is directly attributable to intimate partner abuse (Golding
Jejeebhoy 1998). In well-designed studies, the outcome most as- 1999; Stark 1996).
sociated with partner abuse is low birth weight, although there is
also evidence for increased risk of miscarriage (Gazmararian 2000;
The impact of intimate partner abuse on health
Taft 2004), preterm birth (Lipsky 2003), and foetal injury (Mezey
service usage
1997). A retrospective population-based cohort study in Australia
showed that pregnant women who were hospitalised for an in- Women experiencing intimate partner abuse present to health ser-
cident of interpersonal violence carried almost twice the risk for vices very frequently and require wide-ranging medical services
adverse maternal complications compared with the non-exposed (Campbell 2002; Davidson 2001; Plichta 2007). They are ad-
group, and the overall risk for adverse foetal complications like- mitted to hospital more often than non-abused women and are
wise increased twofold (Meuleners 2011). prescribed more medication (Kernic 2000; Wisner 1999), partic-
ularly analgesia (Lo Fo Wong 2007). A Canadian study set in a
hospital accident and emergency department showed that abused
Psychosocial health of abused women women access medical care three times more often than non-
Mental health problems are common sequelae of partner abuse abused women (Ratner 1993). There is also evidence of a positive
(Ellsberg 2008; Rees 2011), with many survivors reporting that linear relationship between severity of abuse and the use of health-
it is the psychological abuse, rather than the physical violence, care services (Koss 1991).
which has the most long-lasting adverse effects on their well-being It is difficult to calculate the economic impact of intimate partner
(Campbell 2002). abuse, but the costs are high. The estimated total cost of domestic
The most prevalent mental health sequelae of intimate partner violence to the UK in monetary terms is GBP 23 billion per an-
abuse are post-traumatic stress disorder, anxiety, and depressive num. This figure includes an estimated cost to the state of GBP
disorders (Coid 2003; Trevillion 2012). These associations are 3.1 billion, a cost to employers of GBP 1.3 billion, and human
also present for perinatal mental health disorders (Howard 2013). suffering costs of GBP 17 billion (Walby 2004). Likewise, stud-
Women living in abusive relationships are two to three times more ies looking at healthcare plans in the United States have found

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 9
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
average healthcare costs to be significantly higher among abused • providing legal, housing, and financial advice;
compared with non-abused women (Bonomi 2009b; Jones 2006). • facilitating access to and use of community resources such
An Australian study estimated that in 2002 to 2003, the costs to as refuges or shelters, emergency housing, and psychological
the community were on the order of AUD 8.1 billion, with the interventions;
main contributors being pain, suffering, and premature mortality • giving safety planning advice; and
(Access Economics 2004). In an update to that study, NCRVWC • providing ongoing support and informal counselling.
2009 estimated that abuse of women resulted in a cost to the com-
A variety of advocates, including trained lay mentors, community,
munity of AUD 13.6 billion in 2009 to 2010 - again due mainly
healthcare, and judicial service employees and volunteers, may
to pain, suffering, and premature mortality. Thus, in addition to
deliver advocacy services for different time periods and at different
the very serious individual health consequences associated with
intensities. Crisis or short-term advocacy is of brief duration and
abuse, there are also wider economic implications for society.
involves the advocate working with the abused woman for a limited
period of time (although the woman may then be referred on to
other more specialised agencies). The duration of such advocacy
Description of the intervention depends on the needs of the abused woman but generally can range
from a single meeting up to about 12 hours (Metters 2009 [pers
Interventions to improve the health consequences for comm]). More intensive, long-term advocacy may involve weekly
women who have experienced intimate partner abuse sessions for up to 12 months. We will explore the heterogeneous
models of advocacy more deeply in the review itself, based on the
Interventions may be primary, secondary, or tertiary. In the context
descriptions of interventions in the primary studies.
of intimate partner abuse, primary interventions are concerned
with preventing the onset of abuse, secondary interventions aim
to prevent further abuse, and tertiary interventions deal with the
consequences of abuse once it has ceased. This review focuses on
How the intervention might work
secondary and tertiary interventions. Advocacy interventions are based around the concept of empower-
A range of interventions to help abused women have been eval- ment: talking through potential solutions with the woman rather
uated. These may be classified as interventions aimed directly at than being prescriptive and telling her what she ought to do, help-
the women (such as the provision of advocacy or therapy) and ing the woman to achieve the goals she has set rather than being di-
those aimed at improving the response of the professionals with rective and setting the goals for her, and helping her to understand
whom they come into contact (such as the introduction of screen- and make sense of the situation and her responses to it (Campbell
ing protocols or the provision of education and training on inti- 1993).
mate partner abuse). In order to have clear evidence about what The aims of advocacy programmes are multifaceted and may in-
professionals can do to safely and effectively decrease the impact of clude helping abused women to access services, guiding them
intimate partner abuse on women, all such interventions need to through the process of safety planning, and improving abused
be evaluated. To this end, we are conducting a suite of systematic women’s physical or psychological health. Advocacy may be of-
reviews evaluating the effectiveness of interventions to improve fered as a stand-alone service or as part of a multi-component
the health outcomes of women who have experienced intimate (and possibly multi-agency) intervention. Trials of complex multi-
partner abuse. This review examines the effectiveness of individ- component interventions are of increasing importance because of
ual advocacy interventions. Our review of programmes to screen the drive to provide the most cost-effective healthcare (Campbell
women for intimate partner violence has already been published 2000). Proponents of multi-component interventions that in-
(O’Doherty 2015). clude advocacy theorise that offering advocacy addresses an abused
woman’s immediate needs, which in turn allows her to be recep-
Advocacy tive to other interventions (such as psychotherapy or child care
management).
In the context of domestic violence services, advocacy is a term that
varies within and between countries, depending on institutional
settings and historical developments around the role of advocates
(Feder 2006a). Advocates, to whom women are often referred from
Why it is important to do this review
doctors or other service providers, engage with abused women to Women experiencing intimate partner abuse have frequent contact
empower them and liaise them with community services. In some with clinicians (Campbell 2002; Davidson 2001; Plichta 2007)
health settings, they may also have a role in bringing about system and consider it appropriate that they ask questions about such vi-
change, catalysing increased recognition by clinicians of women olence (Burge 2005). They also identify healthcare professionals
experiencing abuse. For the purposes of this review we define the as potential sources of non-judgemental, non-directive support,
core activities of advocacy as: as long as they demonstrate an appreciation for the complexity of

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 10
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
intimate partner abuse (Feder 2006b). Historically, however, the reported data on health outcomes and if the findings were poten-
quality of care for women experiencing domestic violence has been tially transferable (e.g. if referral to an external advocacy agency
poor worldwide (Colombini 2008; Stark 1996). Many clinicians was a plausible action by a healthcare professional).
agree that domestic violence is a healthcare issue, but often they
are reluctant to ask about abuse or do not respond appropriately
Types of interventions
if women talk about it (Gerber 2005; Gutmanis 2007; Ramsay
2012; Taft 2004). Such ambivalence is attributed to a number of Any brief (less than 12 hours) or intensive (12 or more hours)
factors, but frequently cited reasons include perceived time con- advocacy intervention compared to no care or usual care.
straints and a lack of knowledge on how to support these women Advocacy could be delivered either on an individual basis or in a
(Hegarty 2001; Waalen 2000). Offering abused women the op- group environment. We included studies if the intervention in-
portunity to receive the services of a domestic violence advocate is corporated safety planning with the woman or facilitated access to
one course of action that clinicians could easily initiate and which and use of community resources, such as refuges or shelters, emer-
would circumvent the barriers they perceive to helping abused gency housing, and psychological care. Provision of these services,
women. Other options include psychological interventions, refuge either with or without ongoing informal support or counselling
or shelter care without advocacy, or a basic first line response for for the woman, was permissible. We also included studies where
healthcare professionals as recommended by the WHO (Feder advocacy was evaluated as an adjunct to another intervention, such
2013; WHO 2013b). Before recommending that clinicians who as the teaching of child management skills. In our earlier review we
care for women experiencing intimate partner abuse initiate ad- specified that multi-component intervention studies would only
vocacy, however, it is first essential to establish the effectiveness of be included where advocacy was the sole difference between the
the interventions. The current review is an update of a review pub- two trial arms (e.g. both arms would receive intervention A, but
lished in 2009 (Ramsay 2009) and follows the same basic protocol only one arm would receive the second intervention of advocacy).
(Ramsay 2005b); any revisions to this protocol are highlighted in For the present review, however, we also included trials evaluating
the section ’Differences between protocol and review’. multi-component interventions where advocacy plus some other
form of intervention was compared with no care or usual care.
The review team judged that this change was necessary given the
increasing number of trials evaluating advocacy within the context
of multi-component interventions.
OBJECTIVES Similarly, for this updated review we have also incorporated a
To assess the effects of advocacy interventions within or outside more rigorous definition of ’usual care’. We have defined this as
healthcare settings in women who have experienced intimate part- care typically offered in the study setting, with the condition that
ner abuse. such care only includes a minimal element of advocacy (such as
the provision of information cards or leaflets listing the addresses
and telephone numbers of local support agencies), or, if more
substantive advocacy is offered, then less than 20% of women in
METHODS the control arm received such care. The review team judged that
this change was necessary given the increasing use of advocacy as
part of usual care.
Criteria for considering studies for this review
Types of outcome measures
Types of studies We used the incidence of physical, sexual, emotional, and overall
abuse as primary outcomes in Summary of findings for the main
Any randomised (i.e. random sequence generation) or quasi-ran-
comparison and Summary of findings 2, presenting findings for
domised (i.e. alternate allocation, allocation by birth date) con-
intensive advocacy interventions and brief advocacy interventions,
trolled trials (RCTs or quasi-RCTs) that allocated participants or
respectively.
clusters of participants to an advocacy intervention compared with
no care or usual care.
Primary outcomes

Types of participants
Women aged 15 years and over who have experienced intimate Incidence of any form of abuse
partner abuse. Eligible studies could recruit women in healthcare 1. Physical
settings as well as any other settings (such as criminal justice facil- 2. Sexual
ities, refuges/shelters, domestic violence agencies) if these studies 3. Emotional

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 11
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
4. Financial Socioeconomic outcome measures
5. Other (such as risk of death, harassment, reproduction 1. Income
coercion) 2. Housing
Abuse could be assessed using self-reported measures (such as 3. Participation in education
Composite Abuse Scale (CAS; Hegarty 2005), Index of Spouse 4. Participation in work
Abuse (ISA; Hudson 1981), Women’s Experience with Battering
(WEB; Smith 1995), Conflict Tactics Scale (CTS; Straus 1979),
or a single question about continuing abuse) or from observations ’Proxy’ or intermediate outcome measures (including uptake
of abuse in medical or police records. of referrals to other agencies)
1. Use of safety behaviours (e.g. use of coded telephone
messages to a friend, keeping clothes at a friend’s house, hiding
Psychosocial health emergency money)
1. Quality of life (measures such as 36-item Short Form 2. Use of refuges/shelters
Health Survey, or SF-3; Ware 1992) 3. Use of counselling
2. Depression (measures such as Center for Epidemiologic 4. Calls to police
Studies Depression Scale, or CES-D; Radloff 1977) 5. Filing of police reports
3. Anxiety (measures such as Spielberger’s State-Trait Anxiety 6. Solicitation of protection orders
Inventory, or STAI; Spielberger 1983) 7. Maintenance of family ties (i.e. children staying with
mother)
We recognised that postintervention changes in some of these
Secondary outcomes proxy measures may be associated with both positive and nega-
tive health outcomes for abused women and require careful inter-
pretation. For instance, increased refuge/shelter usage may reflect
Physical health proactive behaviour on the behalf of abused women, but it may
1. Deaths, all-cause and partner abuse-related (documented in also reflect an escalation of violence that has led to the women
medical/police records or regional and national databases) needing to seek safety. Where authors reported any adverse out-
2. Physical injuries, such as fractures and bruises (self-reported comes from interventions, we recorded and discussed them in the
or documented in medical and dental records) narrative summary.
3. Any chronic health disorders, such as gynaecological
problems, chronic pain, and gastrointestinal disorders (self- Timing of outcome assessment
reported or documented in medical and dental records)
We documented the duration of follow-up in all included studies.
4. Any general measures of physical health (measures such as
We do not know the optimal period of follow-up. Thus, while
Daily Symptoms Questionnaire, DSQ; Terluin 2006)
an intervention may have some immediate positive effects on the
5. Birth outcomes (self-reported or documented in medical
health of an abused woman (such as a reduction in physical vi-
records)
olence), other outcomes may not be so readily apparent. For ex-
ample, even many months after leaving an abusive relationship,
Psychosocial health a woman may be traumatised, and positive mental health effects
may not be evident for some time. For the purposes of this re-
1. Post-traumatic stress (measures such as Impact of Events view, we defined short-term follow-up as up to and including 12
scale, or IES; Horowitz 1979) months, medium-term follow-up as more than 12 and up to 24
2. Self efficacy (measures such as General Self Efficacy Scale, months, and long-term follow-up as more than two years.
or GSES; Schwarzer 1995)
3. Self esteem (measures such as Rosenberg Self Esteem Scale,
or SES; Rosenberg 1989)
4. Perceived social support (measures such as Sarason’s Social
Search methods for identification of studies
Support Questionnaire, or SSQ; Sarason 1983) We searched the international literature for peer-reviewed and
5. Alcohol or drug abuse (measures such as Addiction Severity non-peer reviewed studies. We did not use a study methods filter
Index, or ASI; McLellan 1980) because we wanted the search to be as inclusive as possible. No lan-
6. Attempted suicide (self reported or documented in medical guage limits were applied. We ran the first searches for this update
records) in September 2011 and March 2013, except for ASSIA and the
7. Self harm (self reported or documented in medical records) British Nursing Index, which we ran in June and August 2013. We
8. Impact on relationships (self reported) updated the search again in March 2014, except for ASSIA and the

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 12
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
British Nursing Index, which we searched in April 2014. A further We searched the websites of the WHO (who.int/topics/
updated search was undertaken in April 2015. The authors of the violence/en) and Violence Against Women Online Resources (
original review searched the National Research Register, but as this vaw.umn.edu) in 2008, 2013 and 2014. We also searched the
database was discontinued in September 2007 we replaced it with Violence Prevention website (preventviolence.info) in 2014. We
UK Clinical Research Network Study Portfolio. Similarly, the Ma- accessed other women’s health and domestic violence websites
ternity and Infant Care database (M&IC) replaced the Midwives through links from full-text articles obtained during the primary
Information & Resource Service (MIDIRS). search. We explored these websites for relevant material or cita-
tions in a non-systematic manner.
Electronic searches
We searched the following list of electronic databases for this up- Handsearching
dated review in October 2011. Since then, we have rerun the
In 2004, we handsearched the following journals from 1980 to
searches three times, most recently in April 2015 (except where
September 2004: American Journal of Public Health, Australian and
noted). The exact search dates and strategies for each source are
New Zealand Journal of Public Health, Journal of Family Violence,
reported in Appendix 1. The search strategies for the previous ver-
Medical Journal of Australia, Violence and Victims, and Women’s
sion of the review (up to 2008) are reported in Appendix 2.
Health. We did not find any additional papers and so did not
1. Cochrane Central Register of Controlled Trials
update handsearches beyond September 2004.
(CENTRAL; 2015, Issue 3; part of The Cochrane Library, and
which includes the Specialised Register of the Cochrane
Developmental Psychosocial and Learning Problems Group). Citation tracking
2. Ovid MEDLINE (1948 to April Week 1 2015). We examined the reference lists of included papers and tracked
3. EMBASE (1980 to 2015 Week 9; Ovid). citations forwards.
4. PsycINFO (1806 to April Week 1 2015; Ovid).
5. CINAHL Plus (1937 to current; EBSCOhost).
6. ASSIA (1987 to current; Cambridge Scientific Abstracts). Other search strategies
Last searched in April 2014, after which it was no longer In order to check for possible omissions, we emailed the first or
available to us. corresponding authors of all primary studies included in the re-
7. Social Science Citation Index (SSCI; 1970 to 13 April view. We also emailed relevant researchers, members of intimate
2015; Web of Science). partner abuse groups, and related organisations around the world,
8. International Bibliography of Social Sciences (IBSS; 1951 and we contacted an informal network of domestic violence re-
to current; ProQuest) searchers in Europe as well as the Department of Reproductive
9. British Nursing Index (BNI; 1994 to current; Proquest). Health and Research at the WHO headquarters in Geneva.
Last searched April 2014, after which it was no longer available
to us.
10. Health Management Information Consortium (HMIC;
1979 to March 2015; Ovid). Data collection and analysis
11. Maternity and Infant Care (1971 to March 2015; Ovid).
12. Cochrane Database of Systematic Reviews (CDSR; 2015,
Issue 4; part of The Cochrane Library). Selection of studies
13. Database of Abstracts of Reviews of Effects (DARE; 2015, We ran the searches twice for the original review (Ramsay 2009);
Issue 1; part of The Cochrane Library). once in 2006 and again in July 2008. We ran the searches four
14. MetaRegister of Controlled Trials (mRCT; isrctn.com/ times for this update (September/October 2011, March to August
page/mrct; all available years to March 2014). Not searched in 2013, March to April 2014, and April 2015).
April 2015 as website reported the service was “under review”. Two review authors (in 2006, JR and either CR or DD; in 2008,
15. WHO International Clinical Trials Registry Platform JR and GF; in 2013, JR and either LS or CR; in 2014, CR and KH;
(ICTRP; all available years; apps.who.int/trialsearch). and in 2015, CR and CB) independently reviewed the abstracts
16. UK Clinical Research Network Study Portfolio (all available of articles identified by the search. Where possible, review authors
years; public.ukcrn.org.uk/search). resolved disagreements by discussion. When they could not reach a
consensus, a third review author (GF in all cases) decided whether
Searching other resources the study potentially fulfilled the inclusion criteria. We sought
additional information from two study investigators in order to
resolve inclusion queries at the abstract stage for the original review
Websites (Trifone 1994) and this update (Grip 2011).

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 13
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Two review authors retrieved the full articles for selected abstracts educational background.
and independently assessed each of the articles against the inclu- 3. Interventions: brief descriptions of intervention (including
sion criteria. For the original review, there were no disagreements frequency and duration of intervention events) and usual care
between the two reviewers about the appropriateness of a study provided.
for inclusion in the review. At the update, the wider review team 4. Outcomes: timing of follow-up events, outcomes assessed,
was called on to discuss the potential inclusion of four studies and scales used.
(Bair-Merritt 2010; Jouriles 2001; Jouriles 2009; Kiely 2010). 5. Notes: where necessary, further information to aid
understanding of the study.
Data extraction and management
Working in pairs (JR, CR, DD, LS), one review author extracted Assessment of risk of bias in included studies
data from included studies and entered it onto electronic collec- Risk of bias was assessed independently by two review authors
tion forms, requesting any missing information from the first or (JR and GF for the 2009 review, and JR and either LS or CR
corresponding authors of papers. We explicitly noted all instances for the 2013/14/15 update) in accordance with the Cochrane
of additional statistical data being provided by the study investi- Handbook for Systematic Reviews of Interventions (Higgins 2008a,
gators in the text (see ’Effects of interventions’). A second author Higgins 2008b). Review authors independently assessed the ex-
independently checked all data extractions. There were no new tent to which each study attempted to control for six potential
data extractions in 2015. The two review authors resolved all dis- types of bias and assigned ratings of ’low risk of bias’, ’high risk
agreements by discussion, and there was no need for adjudication of bias’, or ’unclear risk of bias’ accordingly. We assessed studies
by a third author. All relevant extracted data were entered into as being at overall high risk of bias when there were at least three
Review Manager (RevMan 2014). criteria conferring high risk of bias, or when one or two criteria
We recorded the following information in the ’Characteristics of were associated with high risk of bias (red in Figure 1) and the
included studies’ tables. number of criteria with an unclear risk (yellow in Figure 1) ex-
1. Methods: randomisation method, intention-to-treat ceeded the number of criteria with a low risk (green in Figure 1).
analysis, and power calculation. We defined low overall risk of bias as occurring when a study had
2. Participants: setting, country, inclusion criteria, exclusion no high risk indicators and a maximum of two criteria conferring
criteria, numbers recruited, numbers dropped out, numbers uncertain risk. We classified all other studies as having a moderate
analysed, age, ethnicity, socioeconomic status indicators, and or intermediate risk of bias.

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 14
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Figure 1. Risk of bias summary: review authors’ judgements about each risk of bias item for each included
study. Red circles with minus signs indicate high risk, green circles with plus signs indicate low risk, and yellow
circles with question marks indicate unclear risk of bias.

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 15
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Sequence generation
Baseline measurement of outcome measures
Description: The study contained a sufficiently detailed descrip-
Description: Studies contained information on the comparability
tion of the method used to generate the allocation sequence so
of the groups in terms of the primary outcome measures at baseline.
as to enable an assessment of whether it should have produced
Review authors’ judgements: Were the primary outcomes compa-
comparable groups.
rable between groups at baseline?
Review authors’ judgement: Was the allocation sequence ade-
Ratings: Low risk of bias, high risk of bias, or unclear risk of bias.
quately generated?
Ratings: Low risk of bias, high risk of bias, or unclear risk of bias.
Reliability of primary outcome measures
Allocation concealment Description: Investigators assessed the primary outcomes using
reliable measures (e.g. Cronbach’s alpha 0.6 or above).
Description: The study contained a sufficiently detailed descrip-
Review authors’ judgements: Did investigators assess the primary
tion of the method used to conceal the allocation sequence, en-
outcomes using reliable measures?
abling an assessment of whether participants and staff could have
Ratings: Low risk of bias, high risk of bias, or unclear risk of bias.
foreseen intervention schedules before or during recruitment.
Review authors’ judgement: Was allocation adequately concealed?
Ratings: Low risk of bias, high risk of bias, or unclear risk of bias. Protection against contamination
Description: Investigators described any measures taken to pre-
Blinding vent or minimise the possibility that women in the control arm
Description: The studies described any measures used to blind out- might receive part or all of the intervention so as to assess possible
come assessors in sufficient detail so as to assess possible knowledge contamination between groups.
of which intervention a given participant might have received. Review authors’ judgements: Did the study investigators take steps
Review authors’ judgement: Was knowledge of the allocated in- to prevent or minimise contamination?
tervention adequately prevented during the study? Ratings: Low risk of bias, high risk of bias, or unclear risk of bias.
Ratings: Low risk of bias, high risk of bias, or unclear risk of bias.
Measures of treatment effect
Incomplete outcome data
Description: Studies reported (or authors provided) data on attri-
Binary outcomes
tion, including the numbers involved (compared with total ran-
domised) and the reasons. For binary outcomes, a standardised estimation of the odds ratio
Review authors’ judgement: Were incomplete data dealt with ad- (OR) with a 95% confidence interval (CI) was calculated. If studies
equately by the authors? (See also ’Dealing with missing data’). did not report, or the authors did not provide, the data to calculate
Ratings: Low risk of bias, high risk of bias, or unclear risk of bias. the OR, we provided the findings as stated by the study authors.

Selective outcome reporting Continuous outcomes


Description: Investigators attempted to assess the possibility of We analysed continuous data where means (or mean changes) and
selective outcome reporting. standard deviations (SD) were available from the reports or the
Review authors’ judgement: Were reports of the study free of sug- study authors. In those instances where means and SDs were not
gestion of selective outcome reporting? available, we provided the findings as reported by the study au-
Ratings: Low risk of bias, high risk of bias, or unclear risk of bias. thors. Where mean changes and SDs were reported but the distri-
bution was skewed (most likely because of the small sample size),
we assumed a normal distribution and analysed the data accord-
Other sources of bias ingly. The majority of studies included in the review used a range
Was the study apparently free of other problems that could put it of scales to measure similar outcomes, so we standardised the treat-
at a high risk of bias? ment effects for these outcomes by dividing the mean difference
We specified a priori that the following three criteria would be (MD) in postintervention scores or change from baseline scores
assessed under the heading ’Other sources of bias’. for the intervention and control groups by the pooled SD of the

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 16
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
outcome among participants, generating a standardised mean dif- and scales for measuring outcomes, which were often not compa-
ference (SMD) with 95% CIs. For the few outcomes that were rable. For example, some studies reported a total score for an out-
assessed using the same scale, we calculated the MD. We were come, while others reported only the subscale totals of different
slightly constrained by the way studies reported these data, given measures.
that the MD in postintervention scores and mean change from For studies included in a meta-analysis, we assessed the consistency
baseline scores are not identical, but we have stated the measure of results visually and by examining the I² statistic, which estimates
used in the results. the proportion of variation in point measures due to heterogeneity
rather than sampling error (Higgins 2002).

Unit of analysis issues


For cluster-randomised controlled trials, where the clustering unit Assessment of reporting biases
was an organisation (e.g. general practice), we used results directly The small absolute number of studies that could be pooled in this
from publications that accounted for clustering, or we contacted review precluded the use of funnel plots. Please see Table 1 for
authors to provide results that accounted for clustering. Where methods archived for future updates of this review.
clustering was by time period (e.g. weeks), we assumed that the
intracluster correlation coefficient (ICC) would be small and did
not account for clustering.
Data synthesis
Where comparable data were available, we planned to perform
Dealing with missing data meta-analyses. The decision whether to pool data in this way was
Missing data and dropout rates were assessed for each of the in- determined by the comparability of populations and interventions
cluded studies. The ’Characteristics of included studies’ tables (clinical heterogeneity); the duration of follow-up (methodolog-
specify the number of participants included in the final analysis as ical heterogeneity); and the outcomes being used in the primary
a proportion of all participants in the study. Where available, we studies (see ’Assessment of heterogeneity’). Where it was inappro-
provided the reasons given for missing data in the narrative sum- priate to combine the data in a meta-analysis, we have presented
mary. We assessed the extent to which studies conformed to an in- the effect sizes and 95% CIs for individual outcomes in individual
tention-to-treat analysis. For dichotomous measures, we planned studies. Fixed-effect models were used in all analyses given that all
to run best case and worst case scenario analyses to estimate the meta-analyses were based on subsets of studies that were deemed
effects of missing data on the results of all studies that were pooled. clinically heterogeneous.
This meant that we were able to ascertain if observed effect sizes
increased or decreased as a function of the extent of attrition in the
two arms (intervention and control) of the trial. We tested four Subgroup analysis and investigation of heterogeneity
assumptions: that women who dropped out of the intervention We did not identify enough studies meeting our criteria to per-
would have improved outcomes while women who dropped out of form subgroup analyses as planned in the protocol for this review.
the control arm would not; that women who dropped out from the Methods archived for future updates appear in Table 1.
intervention and control groups would both have improved out-
comes; that women who dropped out of the intervention would
not have improved outcomes while women who dropped out of Sensitivity analysis
the control arm would; and that neither women in the interven-
tion nor in the control groups who dropped out would have im- We did not identify enough studies meeting our criteria to per-
proved outcomes. form sensitivity analyses as planned in the protocol for this review.
Methods archived for future updates appear in Table 1.

Assessment of heterogeneity
There was considerable clinical heterogeneity across the studies Summary of findings table
in relation to differences in the intensity of the advocacy inter- We developed the ’Summary of findings’ tables using the Cochrane
ventions provided, the severity of abuse experienced, the setting Collaboration’s Grades of Recommendations, Assessment, Devel-
where advocacy was provided, the ethnicities (including whether opment, and Evaluation (GRADE) wizard function, GRADEpro-
minority or not) of participants, whether or not advocacy was part filer (GRADEpro 2014), assessing the quality of the body of ev-
of a multi-component intervention, and the outcomes measured. idence for each outcome. We used our ’Risk of bias’ assessments
There was also considerable methodological heterogeneity with in combination with GRADE criteria, such as sample size and
regard to randomisation, control arm design, follow-up timing, dropout, in order to determine quality.

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 17
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Future updates
Review authors intend to update this review after a period of three
years.

RESULTS

Description of studies

Results of the search


See Figure 2 for the flow diagram.

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 18
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Figure 2. Review flow diagram.IPV: intimate partner violence; RCT: randomised controlled trial.

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 19
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
We ran initial searches in 2006 for a much wider ’scoping’ review of
the intervention literature around intimate partner abuse. For this (McFarlane 2000) or week (McFarlane 2006) they presented to
broad search, we found approximately 17,700 records. One of the a healthcare facility, while Taft 2011 used the site as the unit of
questions we addressed in the scoping review was whether women- randomisation. Four trials were pilot studies (Constantino 2005;
centred interventions (advocacy, support groups, and psychologi- Cripe 2010; Gillum 2009; Sullivan 1991). Nine of the studies were
cal approaches) were effective in helping to improve the health and conducted in the USA (Constantino 2005; Gillum 2009; Hyman
well-being of abused women and their children; we assessed 228 2001; Kiely 2010; McFarlane 2000; McFarlane 2006; Sullivan
full papers in order to address this question. Of these, 10 RCTs 1991; Sullivan 1992; Sullivan 2002), two in Hong Kong (Tiwari
(2 of which were quasi-RCTs; McFarlane 2000; McFarlane 2006), 2005; Tiwari 2010), one in Australia (Taft 2011), and one in Peru
reported in 18 articles, met inclusion criteria for this review. (Cripe 2010). All trials took place in urban areas.
We re-ran our searches in a more focused manner in July 2008, With the exception of one trial, published as a PhD dissertation
identifying a total of 1021 records. As a result of this search, we (Hyman 2001), all remaining studies were published in peer-re-
assessed the full text of two additional papers (both of which were viewed journals.
subsequently excluded, one because it had no intervention and
one because it considered HIV/STDs, with no separate data for
abused women). Recruitment
For the present update, we initially re-ran the searches in Septem- Eight of the studies recruited women in healthcare settings (Cripe
ber 2011 and then again in March 2013 (with two databases be- 2010; Gillum 2009; Hyman 2001; Kiely 2010; McFarlane 2000;
ing searched in June and August 2013), March 2014 (with two McFarlane 2006; Taft 2011; Tiwari 2005), and three in domes-
databases searched in April 2014), and April 2015. We found a tic violence shelters (Constantino 2005; Sullivan 1991; Sullivan
total of 11,112 records. Sixty-two full-text articles were identified 1992). One recruited participants primarily from domestic vi-
for further review, and of these, we selected five new RCTs for in- olence shelters but also from social and family service agencies
clusion in the review. We also found three additional studies, but (Sullivan 2002) and one primarily from a community centre serv-
these are not included in this update because of unavailable sub- ing a large urban population (Tiwari 2010). It is possible that
group data for Bair-Merritt 2010, and unavailable data for Niolon women recruited in healthcare settings differ from those recruited
2009 and Prosman 2014. All three studies are currently awaiting elsewhere, as they may not yet be ready to accept help (Zink 2004).
assessment (Studies awaiting classification). One study recruited additional participants after the initial six-
Four potentially relevant but still ongoing studies have been month follow-up period (Sullivan 1992), raising the number of
identified since the original review (Lako 2013; NCT01207258; recruited women from 146 at the outset of the study to a total
NCT01661504; NCT00465556), but data are not yet available of 283 at the two-year follow-up. However, investigators’ report
for these. We aim to include these in the next update if relevant. of the three-year follow-up data was based only on the original
sample.
Included studies The papers did not always explicitly state the severity of the abuse
experienced by participants, but for the most part, it could be in-
Thirteen studies, reported in 21 papers, met the criteria for inclu- ferred from the study setting or the mean baseline abuse scores.
sion in this review (Constantino 2005; Cripe 2010; Gillum 2009; For the four trials recruiting women either exclusively or primar-
Hyman 2001; Kiely 2010; McFarlane 2000; McFarlane 2006; ily from domestic violence shelters (Constantino 2005; Sullivan
Sullivan 1991; Sullivan 1992; Sullivan 2002; Taft 2011; Tiwari 1991; Sullivan 1992; Sullivan 2002), it is likely that the women
2005; Tiwari 2010). Where studies report data in more than one had experienced relatively severe abuse; mean baseline abuse scores,
paper, we only use the primary reference (or the paper deemed available for two of the studies, support this (Sullivan 1991;
most relevant if published within the same year). Sullivan 1992). For the eight studies recruiting participants in
All but two included studies were RCTs; the quasi-RCTs were healthcare settings, the severity of the abuse varied. In Hyman
McFarlane 2000 and McFarlane 2006. In 10 studies, the women 2001, which was set in a hospital emergency department, 90% of
were the unit of randomisation (Constantino 2005; Cripe 2010; participants reported having been physically or sexually assaulted,
Gillum 2009; Hyman 2001; Kiely 2010; Sullivan 1991; Sullivan 93% were experiencing ongoing abuse, and 68% had received pre-
1992, Sullivan 2002; Tiwari 2005; Tiwari 2010). Three stud- vious medical treatment for injuries. The severity of abuse experi-
ies were cluster-randomised (McFarlane 2000; McFarlane 2006; enced by participants at study entry in the remaining healthcare
Taft 2011). McFarlane and colleagues used a method whereby the trials (based in antenatal, primary care/public health, mother and
weeks or months were randomly allocated to intervention and con- child clinics, and GP practices) was mostly less severe. Mean base-
trol, and then the women were allocated according to the month line scores indicated that women experienced moderately severe

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 20
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
physical and psychological abuse at study entry in three studies The models of advocacy employed in the trials were heterogeneous.
(McFarlane 2000; McFarlane 2006; Taft 2011), while in Cripe
2010 and Tiwari 2005, participants reported moderate-to-severe
psychological abuse, but less severe levels of physical and sexual Content
abuse. In Kiely 2010, instances of minor abuse were common, but The papers did not always explicitly state the theoretical frame-
55% of the women had also experienced severe abuse. In Gillum work underlying each intervention. However, in general, the advo-
2009, one-third of the participants met the criteria for being in cacy provided to the participants was based on the concept of em-
lethal danger. In the one study set in the community, the most powerment and included education, advice on safety and access-
prevalent form of abuse was psychological aggression (on average, ing resources, and empathic support. All of the interventions were
19 events per woman), although a minority of women had also pragmatic in that they provided tailored services to meet the wants
been physically assaulted or sexually coerced (Tiwari 2010). and needs of the individual women. Some used the term ’coun-
selling’, ’supportive listening’ or ’peer counselling’ to describe fa-
cilitation of access to resources. Thus, Gillum 2009 gave resource
Participants information to participants in the control arm, while advocates
A total of 2141 abused participants took part in the trials. Most actively helped to engage women in the intervention group with
of these women (n = 1297; 61%) were recruited because they resources as part of an intervention, thus fitting our criteria.
were experiencing current (within the last 12 months) physical Tiwari 2010 used an empowerment intervention with a comple-
or sexual abuse. Seven studies extended inclusion beyond this to mentary focus on accessing resources. Authors explicitly stated,
also include women experiencing emotional or non-physical abuse “The aim of empowerment training is to increase women’s safety
(Constantino 2005; Cripe 2010; Gillum 2009; Hyman 2001; Taft through the recognition of increased danger, paired with a safety
2011; Tiwari 2005; Tiwari 2010). Many of the participants were plan developed for individual use. In addition, it provides informa-
living with or still intimately involved with the perpetrator at tion about the cycle of violence, facts, and options regarding part-
study entry. However, there were exceptions to this. In Sullivan ner violence, legal protection orders, filing for criminal charges,
2002, 79% of the women were no longer involved with the abu- and community resources for abused women.” Thus, this multi-
sive partner. In four other studies, it was not clear how many of component, heterogeneous intervention entailed resource identi-
the women were still intimately involved with the abuser at re- fication and facilitated their access to women in the intervention
cruitment (Constantino 2005; Cripe 2010; Gillum 2009; Kiely arm, hence fulfilling our inclusion criteria.
2010). The ages of the women recruited ranged from 15 to 65 One of the studies evaluated a group intervention that allowed
years, although more usually the women were aged between 24 for participant-participant interaction, as well as interaction be-
and 45 years old. The ethnicity of the samples varied across trials. tween the intervention participants and the advocate (Constantino
Seven studies included a mix of whites, African Americans and 2005). Authors labelled this a ’social support intervention’. How-
Latinas, with two of the studies considering the possible effects of ever, there was no structured psychological intervention, and the
acculturation (McFarlane 2006) and race (Sullivan 1992) on out- intervention focused on accessing community resources, includ-
comes at three year follow-up. Four trials involved single ethnic ing information on resources and hours of operation for those re-
groups, including a study reporting on Latina women (McFarlane sources when available. It therefore fits our inclusion criteria. Three
2000), one recruiting African American women (Kiely 2010), and trials included components in addition to advocacy that may have
two studies conducted in Hong Kong in which all participants impacted the outcomes reported. The first of these included ad-
were Chinese (Tiwari 2005; Tiwari 2010). A further trial predom- vocacy and education/support for all the children of mothers who
inantly (87%) recruited women identifying their ethnicity as Mes- had been abused (Sullivan 2002), while the second provided par-
tizo (Cripe 2010). One study, set in Australia, stated that 17% of enting support to all the abused mothers (Taft 2011). The third
those recruited to the intervention arm and 7% of those recruited study was more complex, providing advocacy within the context
to the control arm were born in Vietnam, and 17% and 32% in of three possible further (and separate) interventions, depending
the intervention and control arms, respectively, were born in other on the abused woman’s risk profile: cognitive behavioural ther-
countries outside Australia (Taft 2011). The socioeconomic status apy (CBT) if depression was a risk, and smoking cessation/reduc-
of participants was mixed, but most of the women were on low tion sessions if smoking or environmental tobacco smoke exposure
incomes, and few had university studies. Only in two studies did a were identified risks (Kiely 2010).
reasonably high proportion of the women either have a university
education (Hyman 2001) or an income that was above average for
the country (Tiwari 2005). Advocates
Trained advocates administered all of the interventions, though
there was some variability in their professional status. A pro-
Interventions fessional advocate led one of the interventions (Hyman 2001),

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 21
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
research nurses administered three others (Constantino 2005; session lasting about 30 minutes, followed by six telephone calls
McFarlane 2006; Tiwari 2005), social workers and psychologists over a three-month period, each lasting an average of 20 minutes
provided three others (Cripe 2010; Kiely 2010; Tiwari 2010), (range 5 to 60 minutes) (Woods 2013 [pers comm] in Gillum
and trained paraprofessional students an additional three (Sullivan 2009). We assessed this intervention as being approximately 2.5
1991; Sullivan 1992; Sullivan 2002). One study provided a mix- hours long. In the fourth study, advocacy for abuse (and where
ture of face-to-face advocacy with the study investigators plus tele- applicable, therapy for depression and smoking/passive smoking)
phone support from trained community health workers (Gillum was provided at four to eight prenatal sessions and two postpar-
2009). Two studies were somewhat different in that they evaluated tum booster sessions (Kiely 2010). Depending on how many of
the effectiveness of advocacy provided by ’mentor mothers’. In the four risks were addressed, each session lasted 50 ± 15 minutes,
the first of these, the services of a trained, non-professional ’men- for a total of 3.5 to 8 hours of advocacy. The one study recruiting
tor mother’ supplemented advocacy by a professional advocate in healthcare clinics that was of longer duration was conducted
(McFarlane 2000), while in the second, trained, non-professional in Australia (Taft 2011). The total duration of this intervention
’mentor mothers’ provided the entirety of the intervention (Taft is not specified in the paper, but abused women were offered a
2011). With one exception, all of the interventions assessed were minimum of one hours’ advocacy each week for 12 months, for
new and non-established modes of care within the study settings. at least 52 total hours of advocacy.
The exception to this was a trial that evaluated two modes of in-
terventions already in regular use in an emergency room (Hyman
2001). Range of control conditions
Control conditions also varied. One study compared the inter-
vention with usual shelter care and unstructured chats with the
Duration principal investigator (Constantino 2005). In five studies, women
were provided with a referral card listing useful community agen-
The duration of the interventions varied considerably and, to a cies (Cripe 2010; Gillum 2009; McFarlane 2000; McFarlane
large extent, was related to the settings in which the women were 2006; Tiwari 2005); the women also received health information
recruited. brochures in two studies (Gillum 2009; McFarlane 2000) and a
In general, the interventions described in studies outside of health- safety plan in another (McFarlane 2006). In one study, women
care settings were longer, both in terms of the length of the ses- in the control group also received an information sheet, includ-
sions and the period over which the sessions were offered. Typi- ing community resource details (Taft 2011). In Hyman 2001, the
cally, these types of interventions took place over a period of two control group received standard care from social services; in Kiely
to four months, providing advocacy for respective totals of about 2010, they received usual prenatal care, and in Sullivan 1991,
12 hours (Constantino 2005), 43 hours plus an additional 80 Sullivan 1992, and Sullivan 2002, they received usual shelter care.
hours provided to the children (Sullivan 2002), and 60 to 80 hours In Sullivan 1992, usual after-shelter care was also included within
(Sullivan 1991; Sullivan 1992). The one exception is the study the study. In Tiwari 2010, women in the control group did not
that recruited women within a community centre setting (Tiwari receive any specific care; however, recruitment took place at a
2010); an initial face-to-face session (lasting about 30 minutes) community centre that provided various community resources, to
was followed by 12 weeks of telephone advocacy (about 10 to 20 which they naturally had easy access.
minutes per call) for an accumulated total of 2.5 to 4.5 hours of
advocacy.
Most interventions recruiting women in healthcare settings were Outcomes
relatively brief. Three interventions were one-off sessions and In terms of our primary outcomes, 11 of the 13 studies measured
lasted from 20 to 30 minutes (Tiwari 2005), about 30 minutes some form of abuse (using eight different scales), six assessed qual-
(Cripe 2010), and 90 minutes (Hyman 2001). Four other tri- ity of life outcomes (three scales), six measured depression (three
als offered advocacy sessions over a prolonged period but were scales), and three studies measured anxiety or psychological dis-
still of brief duration overall. In the first of these, women were tress (three scales). There was little consistency across the trials in
recruited in antenatal clinics and offered advocacy (or advocacy relation to the scales used to measure any of these outcomes.
plus the services of a ’mentor mother’) until the time of their de-
livery (McFarlane 2000). The authors report that most sessions
lasted about 30 minutes, with women averaging four to five ses- Physical abuse
sions for an accumulated total of approximately 150 minutes of Physical violence was the most commonly measured form of
advocacy (McFarlane 2007 [pers comm]). In the second study, abuse. When assessing this outcome, five of the trials (Kiely 2010;
women received five separate 20-minute interventions, each six Sullivan 1991; Sullivan 1992; Tiwari 2005; Tiwari 2010) used
months apart, for a total of approximately 100 minutes of advo- modified or revised versions of the physical violence subscale of
cacy (McFarlane 2006). The third trial provided one face-to-face the Conflict Tactics Scale (CTS, CTS2; Straus 1996). McFarlane

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 22
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
2000 and McFarlane 2006 employed the physical abuse subscale Sullivan 1992, and Sullivan 2002 all measured depression using the
of the Severity of Violence Against Women Scale (SVAWS 1992), Centre for Epidemiological Studies Depression Scale (CESD-R
Gillum 2009 used the physical abuse subscale of the Partner Abuse 2004).
Scale (PAS; Hudson 2006), and Hyman 2001 used the physical
abuse subscale of the Index of Spouse Abuse (ISA; Hudson 1981).
Anxiety/psychological distress
Three studies measured anxiety/psychological distress: Hyman
Sexual abuse 2001 asked participants to complete the Symptoms Checklist 90-
Tiwari 2005 used a single question to ascertain if sexual abuse Revised (SCL-90-R 1994) in order to obtain the Global Sever-
had occurred, while Gillum 2009 used individual items relating ity Index score, Constantino 2005 asked participants to com-
to sexual abuse from the PAS (Hudson 2006). Kiely 2010 and plete the Brief Symptom Inventory (BSI 1993), and Sullivan 1992
Tiwari 2010 opted for employing the sexual coercion subscale of asked participants to complete the Rape Aftermath Symptom Test
the CTS2 (Straus 1996). (RAST; Kilpatrick 1988).

Emotional abuse Follow-up


Investigators assessed emotional abuse using four measures. Two The duration of the follow-up period varied considerably be-
trials (McFarlane 2000; McFarlane 2006) employed the threats tween studies. Four studies conducted no further follow-up of the
of abuse subscale of the SVAWS (Straus 1996) and two studies ( women after assessing outcomes upon completion of an interven-
Sullivan 1992; Tiwari 2005) used the Index of Psychological Abuse tion (Constantino 2005; Gillum 2009; Kiely 2010; Taft 2011),
(IPA; Sullivan 1991). Gillum 2009 used the non-physical abuse while four trials carried out assessments at 10 weeks (Sullivan
subscale of the PAS (Hudson 2006), and Tiwari 2010 used the 1991), three to four months (Hyman 2001), four months (Sullivan
psychological aggression subscale of the CTS2 (Straus 1996). 2002), and six months (Tiwari 2010). Tiwari 2005 states that
the investigators assessed outcomes at six weeks postdelivery, but
this could represent a follow-up period of anywhere from 16 to
Other aspects of abuse 34 weeks. Similarly, Cripe 2010 followed up women a week af-
McFarlane 2006 and Gillum 2009 also measured other aspects of ter giving birth, or anywhere from 14 to 28 weeks postinterven-
abuse; both studies gauged homicide risk using the Danger Assess- tion. McFarlane 2000 reports data at various time points up to
ment Scale (DA Scale 2004), while McFarlane 2006 evaluated ha- 18 months postintervention, McFarlane 2006 carried out multi-
rassment at work using the Employment Harassment Scale (EHS ple intervention sessions and follow-ups for up to two years, and
1992). Sullivan 1992 reports data at multiple time points for up to three
Investigators from three studies measured overall abuse using dif- years postintervention.
ferent methods. Hyman 2001 combined the physical and non- Some of the papers reported reasons why there was a loss to follow-
physical abuse subscales of the ISA (Hudson 1981), and Sullivan up. The primary reason stated was that some women could not
2002 used a composite of a modified version of the IPA (Sullivan be located (Cripe 2010; Hyman 2001; McFarlane 2006; Sullivan
2006) and the CTS physical violence subscale (Straus 1979). Taft 2002; Tiwari 2005). Other reasons included refusals to carry on
2011 assessed physical, sexual, and emotional abuse through the with the study (Hyman 2001; Sullivan 2002), women returning
Composite Abuse Scale (CAS; Hegarty 2005). to their abusive partner (Sullivan 1991), moving out of the area
(Gillum 2009), and having difficulties with transport, childcare,
or living conditions (Constantino 2005). One study reported no
Quality of life loss to follow-up (Tiwari 2010).
In terms of quality of life, three trials (Cripe 2010; Taft 2011;
Tiwari 2005) asked women to complete the 36-item Short Form
Health Survey (SF-36; Ware 1992). Tiwari 2010 employed the Excluded studies
(SF-12; Ware 1996), and Sullivan 1992 and Sullivan 2002 both For this update we excluded 48 reports (43 studies) after examin-
used an adapted version of a scale by Andrews and Withey ing the full text. We excluded 16 on grounds of design (i.e. they
(Andrews 1976). were not RCTs or quasi-RCTs) (Anderson 2012; Andrews 2011;
Coker 2012; Davidson 2012; Dichter 2012; Ford-Gilboe 2011;
Grip 2011; Jack 2012; Kendall 2009; Kramer 2012; Krishnan
Depression 2012; Orchowski 2012; Peled 2010; Simmons 2011; Song 2010;
Taft 2011 and Tiwari 2005 both used the Edinburgh Postnatal Stover 2010); 18 because the interventions did not meet our
Depression Scale (EPDS; Cox 1987). Tiwari 2010 utilised the criteria for being advocacy-based (Bloom 2014; Carlson 2012;
Beck Depression Inventory II (BDI-II 1996), and Gillum 2009, Eden 2015; Graham-Bermann 2013; Hirani 2010; Houry 2011;

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 23
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Humphreys 2011; James 2014; Johnson 2011; Koziol-McLain having been picked up with the previous search (Bacchus 2007;
2015; Kyegombe 2014; Lindsay 2013; Miller 2011; Miller 2014; Becker 2008; El-Mohandes 2008; McLelland 2008). This is be-
Saftlas 2014; Valpied 2014; Wagman 2015; Zlotnick 2011); two cause we wanted to make the reasons for their exclusion explicit,
because the control groups also received advocacy (Jouriles 2009; taking into consideration recent discussions around definitions of
Tiwari 2010); one because it did not test advocacy (Feder 2011); advocacy.
and one because the control group did not receive usual care It should be noted that although we excluded El-Mohandes 2008
(DePrince 2012). We also excluded one potentially relevant study and El-Mohandes 2011 from this review, the relevant data were
because the women were not abused (Cupples 2011), and four published in a subsequent paper that is included in the review
studies for lack of available data on the subset of women who (Kiely 2010); see ’Characteristics of included studies’ for further
had experienced abuse (Andersson 2013; El-Mohandes 2011; details.
Robinson-Whelen 2014; Saggurti 2014). For more information, please see ’Characteristics of excluded
In addition, we excluded two studies that had featured in the orig- studies’ tables.
inal review following a change in our definition of ’usual care’ (i.e.
studies where usual care included more substantial elements of ad- Risk of bias in included studies
vocacy); we excluded McFarlane 2002 on the basis of information
provided in the published paper, and Jouriles 2001 after commu- To assess the risk of bias in included studies, we applied the eight
nication with one of the authors about the content of the care of- criteria outlined in the ’Methods’ section above (Figure 1 and
fered to participants in the control arm of the trial. Furthermore, Figure 3). Many of our included studies (10 out of 13) satisfied at
we list some studies published in 2007 to 2008 as excluded in least four criteria; however, some of these did not provide enough
this version of the review but not in the previous version, despite data for us to evaluate some of their other potential biases, so
overall, we judged 5 of the 13 studies to be at high risk of bias.

Figure 3. Risk of bias graph: review authors’ judgements about each risk of bias item presented as
percentages across all included studies.

We judged one trial to be at low risk of bias on all eight criteria


(Tiwari 2005) and another study by the same author to be at low of bias, we deemed five others to carry a moderate risk.
risk on seven criteria and unclear on one (Tiwari 2010). Kiely Allocation
2010 was at low risk of bias on six criteria and unclear on two. In
addition to these three studies, which were all at low overall risk
Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 24
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Sequence generation randomisation status. McFarlane 2006 stated that budget limita-
All 13 studies described treatment allocation as random, but only 6 tions precluded the use of blinding, and Taft 2011 stated that the
trials provided sufficient information on sequence generation: one outcome assessors were not blinded, as they had also negotiated
study reported using random numbers tables to allocate partici- informed consent and fully briefed participants about the men-
pants (Hyman 2001), one study wrote the allocations on pieces of toring programme. Similarly, in Gillum 2009, the outcome asses-
paper placed in envelopes that were subsequently shuffled (Gillum sors could not have been blinded as they also collected baseline
2009), and four studies stated that they used a computer-gener- data and provided an initial face-to-face counselling session for
ated method (Kiely 2010; McFarlane 2006; Tiwari 2005; Tiwari women in the intervention group. The other four studies did not
2010). Six studies either made no reference to sequence generation provide sufficient explicit information to enable a judgement on
or provided insufficient details, so we rated their risk of bias as the blinding of assessors, so we judged them to be at unclear risk
unclear. of detection bias.
In the cluster-randomised trial by Taft 2011, a large percentage of
clinics did not refer any potential participants to either arm, hence
we rated this study as having selection bias. Incomplete outcome data
One study was successful in retaining all of the women they re-
cruited (Tiwari 2010). All other studies reported losses over time.
Allocation concealment
In 11 of the remaining 12 trials, losses to follow-up ranged from
Only five trials provided sufficient information and fulfilled the
2.5% in Sullivan 2002 to 27% in Taft 2011. One trial reported
requirement of allocation concealment. Four of these reported
a higher loss of 48% of its recruited sample, so these results need
that the allocations were placed in sealed envelopes (Gillum 2009;
to be interpreted with caution (Hyman 2001). We judged six of
Sullivan 1992; Tiwari 2005; Tiwari 2010), and in the fifth study,
the trials to have a low risk of attrition bias (Cripe 2010; Gillum
the recruiters had to telephone a co-ordinating centre (Kiely
2009; McFarlane 2006; Sullivan 2002; Tiwari 2005; Tiwari 2010).
2010). Three trials did not have any allocation concealment, so
However, five studies carried a high risk of bias (Constantino
we rated their risk of bias as high. Two of these studies randomised
2005; Hyman 2001; Sullivan 1991; Sullivan 1992, Taft 2011).
women to intervention and control groups according to the week
In two cases, and although investigators provided reasons for at-
(McFarlane 2006) or month (McFarlane 2000) they attended a
trition, group allocation might have had an effect on dropout
clinic; for the third study, the investigators maintained allocation
(Constantino 2005; Hyman 2001). We had difficulty in assessing
concealment at the time of randomisation, but thereafter clinic
the significance of attrition in Sullivan 1991 and Sullivan 1992.
staff were aware of their intervention status (Taft 2011). None of
In the former, there was a large difference in attrition between
the five remaining studies made reference to allocation conceal-
groups. This was accounted for by participants becoming ’ineligi-
ment, so we judged them to be at unclear risk of bias.
ble’, as they had to receive at least three weeks of services and had
dropped out (three because they had returned to their abusers).
Blinding This may have influenced the effect sizes of outcomes. However,
Blinding participants or those delivering advocacy interventions we note that the poor attrition is a function of the study design,
is not feasible. where women had to attend at least three advocacy sessions to be
Five of the trials provided details of the measures taken to ensure eligible, a condition which could not apply to women allocated to
blinded assessment of the primary outcomes. Four of these stud- the control group. Similar arguments also apply to Sullivan 1992.
ies provided explicit details on blinding: Hyman 2001 and Kiely Finally, two trials reported testing to see whether attrition had a
2010 each stated that the researchers did not have any information potential effect on results (Kiely 2010; McFarlane 2000). Neither
about randomisation status, while Tiwari 2005 and Tiwari 2010 study reported any significant differences, but they did not report
stated that the researchers did not become aware of the women’s sufficient details about the reasons for attrition or if its relation
randomisation status until after collecting all follow-up data, when to group allocation, so we judged the risk of attrition bias to be
the women started answering questions about their satisfaction unclear.
with the care. The fifth trial did not explicitly assert the extent of
blinded assessment, but we thought it was satisfactory on the basis
of statements in the paper, which remarked that the postinterven- Selective reporting
tion interviewers were different to the interviewers who collected In the review authors’ judgement, there was no indication of se-
baseline data and provided the intervention (Cripe 2010). lective outcome reporting by study investigators. All primary out-
There was no blinded assessment in four of the trials. Sullivan come measures described in the methods were also reported in the
1991 stated that the follow-up interviews with women who re- ’Results’ sections of papers. On occasion, we required the data in a
ceived advocacy were longer and included questions about the pro- different format to that provided in the paper and, where possible,
gramme, thus the researchers must have been aware of the women’s the investigators made such data readily available.

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 25
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Other potential sources of bias according to the week (McFarlane 2006) or month (McFarlane
2000) they presented to the healthcare facility (weeks and months
were randomly allocated to the intervention or control group).
Baseline measurement of outcomes McFarlane 2000 had a design that may have minimised potential
We assessed reporting of baseline measurement of outcomes in contamination; women in the different trial arms were unlikely
all the reviewed studies. In seven, the study investigators stated to come into personal contact with each other, and different in-
that there were no substantive between-group differences in out- dividuals provided the treatments. However, in McFarlane 2006,
come measures at baseline (Cripe 2010; Gillum 2009; Kiely 2010; the change in allocation status was much shorter, and the same
McFarlane 2000; Sullivan 1991; Sullivan 2002; Tiwari 2010 ), healthcare professionals managed both groups, so there was more
while an eighth study stated that there were no between-group potential for the control group to receive elements of the inter-
differences for their larger sample, but they did not provide infor- vention accidentally. We rated this study to be at high risk of bias.
mation in relation to their original sample (Sullivan 1992). Five of The final study employed cluster-randomisation (Taft 2011) and
the trials did not explicitly state that there were no baseline differ- thus was designed to protect against contamination.
ences between groups, but they did report (or we were able to ob-
tain) means and standard deviations, and these looked comparable Effects of interventions
(Constantino 2005; Hyman 2001; McFarlane 2006; Taft 2011;
See: Summary of findings for the main comparison Intensive
Tiwari 2005), so we rated them as also fulfilling this criterion.
advocacy interventions for women who experience intimate
partner abuse versus usual care at up to 12-month follow-up;
Reliable primary outcome measures Summary of findings 2 Brief advocacy interventions for women
All studies measured multiple outcomes. Although they seldom who experience intimate partner abuse versus usual care at up to
stated which were the primary outcomes, this could sometimes 12-month follow-up
be inferred from the sample size calculation (Hyman 2001; Kiely Our synthesis of the outcome data is primarily narrative. The 13
2010; Taft 2011; Tiwari 2005; Tiwari 2010) or from the research studies tracked a wide range of 25 outcome measures, though sev-
question (Gillum 2009; McFarlane 2000). Based on this infor- eral of the studies used some of the same outcomes. Ultimately,
mation, we thought 12 trials had employed reliable measures to however, we were only able to perform a limited number of meta-
evaluate primary outcomes, while one carried an unclear risk of analyses because of problems with the reported data. The first
bias (Cripe 2010). problem was the clinical heterogeneity across the studies in rela-
tion to differences in the intensity of the advocacy interventions
provided. For example, we felt that we could not combine stud-
Protection against contamination ies that tested ’intensive’ interventions (i.e. 12 or more hours of
In 10 studies, the women were the unit of randomisation. One advocacy) with those using ’brief ’ interventions (e.g. less than 12
of these studies reported taking multiple steps to counter possi- hours duration). This substantially reduced the number of studies
ble contamination; these included minimising opportunities for amenable to pooling. A second problem was that a number of the
participants in the different groups to meet or share intervention outcomes were measured in different ways, so we could not com-
materials, not recording a woman’s allocation status in her medi- pare them. For example, some studies reported a total score for an
cal record, and not allowing outcome assessors to be involved in outcome, while others reported only the subscale totals of different
the study design or provision of care (Tiwari 2005). One study measures. This further reduced our ability to pool studies.
reported some contamination, and approximately 19% of women Trials did not always report outcome data in a form that we could
in the intervention group received control group care, while about use in the review. In total, we contacted and obtained further un-
23% of women allocated to the control arm received the inter- published data from eight of the study authors (Constantino 2005;
vention (Hyman 2001). Another trial was also at high risk of con- Gillum 2009; Hyman 2001; Kiely 2010; Sullivan 1992; Sullivan
tamination: the study was conducted in a clinic serving a rela- 2002; Taft 2011; Tiwari 2005). One author (Cripe 2010) was un-
tively small population, so contact between the women was possi- able to send us additional unpublished data. In order to allow for
ble. Moreover, the interventionists had at least some contact with comparison across the studies, two of the review authors (JR and
the control group participants (Gillum 2009). In the other seven either CR or DD for the original review; or JR and CR for the
studies that randomised women on an individual basis, women updated review) independently recalculated all effects sizes. We
in different arms of the trial may have communicated with each have highlighted where our calculated unadjusted effect sizes are
other, so we rated these studies at unclear risk of bias on this do- markedly different from the findings reported by the study investi-
main (Constantino 2005; Cripe 2010; Kiely 2010; Sullivan 1991; gators. We based all analyses on postintervention scores except for
Sullivan 1992; Sullivan 2002; Tiwari 2010). three studies, where changes from baseline data were available for
Three studies randomised participants on a non-individual ba- some or all of the outcomes measured (these are differentiated in
sis. Two studies by McFarlane and colleagues randomised women the forest plots by ’mean change scores’) (Cripe 2010; Constantino

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 26
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
2005; Tiwari 2005). In Cripe 2010, we corrected for differences other from a community centre (Tiwari 2010)-showed no effect
in the direction of mean change by multiplying the reported mean of advocacy in the short-term, that is, at up to 12 months follow-
change scores by − 1. For the one cluster-randomised trial (Taft up (SMD 0.00, 95% CI − 0.17 to 0.16, I² = 0%; moderate qual-
2011), the study authors provided us with design effect sizes for ity evidence). Similarly, there was no effect in the medium term
each of the individual outcomes adjusted for clustering (design (SMD − 0.02, 95% CI − 0.24 to 0.19; n = 319) when McFarlane
effects were minimal, ranging from 0.86 to 1.12). Where inves- 2006 followed up women 24 months after the first intervention
tigators reported multiple follow-ups within our three follow-up session (with sessions being provided thereafter every six months
categories, unless stated otherwise, we chose to report the results for up to two years). However, this pattern of results did not ex-
from the latest follow-up in all comparison analyses. For example, tend to Kiely 2010, the only trial that employed a dichotomous
if data were reported at 2, 6, and 12 months follow-up, we selected measure of physical abuse (Analysis 1.2). In this multi-component
the data at 12 months. study, recruiting within an antenatal setting, women who received
Two of the studies recruited both abused and non-abused women. advocacy (and possibly also cognitive behavioural therapy (CBT),
These either reported on the subset of abused women only (Kiely therapy for smoking/passive smoking, or both) were less likely to
2010), or we obtained separate data for the subset of abused be experiencing physical abuse at the end of the intervention pe-
women from the study authors (Taft 2011). riod (OR 0.42, 95% CI 0.23 to 0.75; n = 306). This means that
Finally, one of the studies continued to recruit participants af- one in every eight women that is given advocacy is likely to benefit
ter taking baseline measurements (Sullivan 1992). For this study, from it (number needed to treat (NNT) = 8). Findings were more
where follow-up data were available for both the original and the equivocal in the study that measured severe and minor abuse in
expanded samples of participants, we calculated effect sizes based pregnant women attending for antenatal care (Tiwari 2005). In
on the latter. In general, the effect sizes for outcomes at up to 12 this study, which had a low risk of bias, a brief 30-minute session
months and 12 to 24 months follow-up were calculated on the of advocacy was not associated with any reduction in severe abuse
larger sample of participants. The two exceptions to this both re- as measured at 16 to 34 weeks postintervention (change-score MD
lated to dichotomous measures of physical abuse and emotional 0.08, 95% CI − 0.26 to 0.42; n = 110; not statistically significant;
abuse as measured at up to 12 months follow-up. All effect sizes moderate quality evidence), but investigators did observe a reduc-
for outcomes measured at 24 + months follow-up were based on tion in minor abuse (change-score MD − 1.00, 95% CI − 1.82 to
the original, smaller sample of participants. − 0.18; n = 110; Analysis 1.3). The fifth trial that offered brief ad-
vocacy did not report any standard deviations, nor were these (or
alternative relevant data) available from the authors (McFarlane
Primary outcomes 2000). However, in their paper, the study authors reported finding
no evidence to suggest that advocacy (or advocacy plus the services
of a ’mentor mother’) reduced physical abuse in women recruited
Incidence of abuse
from antenatal clinics, either in the short or medium term.
Two studies, both recruiting women departing from domestic vi-
Physical abuse olence shelters, assessed the effectiveness of intensive advocacy.
Sullivan 1992 measured physical abuse using both continuous and
Eight studies measured physical abuse; six of these evaluated brief
dichotomous measures, while Sullivan 1991 assessed this outcome
advocacy interventions (Gillum 2009; Kiely 2010; McFarlane
using only a dichotomous measure. In the study that employed a
2000, McFarlane 2006, Tiwari 2005; Tiwari 2010), while the
continuous measure of physical abuse (Analysis 1.4), there was no
other two appraised intensive interventions (Sullivan 1991;
evidence to confirm or refute the hypothesis that advocacy leads to
Sullivan 1992). One study measured both severe and minor phys-
a reduction in severe physical abuse at 12 months follow-up (MD
ical violence separately (Tiwari 2005); this study was also differ-
− 0.12, 95% CI − 0.39 to 0.15; n = 265; low quality evidence)
ent from the others in that it assessed mean change from baseline.
or at three years (MD 0.18, 95% CI − 0.20 to 0.56; n = 124).
One of the studies employed a composite measure of physical and
However, at the two-year follow-up, trialists reported that women
sexual abuse, but we were able to obtain separate data for each of
who received advocacy experienced significantly less physical abuse
these (Kiely 2010). We obtained additional statistical data from
than women in the control arm (MD − 0.25, 95% CI − 0.50
four study investigators (Gillum 2009; Kiely 2010; Sullivan 1992;
to 0.00; n = 265). A similar pattern of results also emerged with
Tiwari 2005).
the dichotomous data (Analysis 1.5). Two studies contributed to
We calculated effect sizes for five of the six studies that offered brief
a meta-analysis of the 12-month follow-up data (Sullivan 1991;
advocacy. As indicated (see Analysis 1.1 in ’Data and analyses’),
Sullivan 1992); there was no evidence that advocacy reduced phys-
there was no evidence that advocacy leads to a reduction in physical
ical abuse (OR 0.61, 95% CI 0.33 to 1.14, I² = 0%; n = 182; very
abuse when this outcome is expressed using a continuous measure.
low quality evidence) with the NNT being eight women for one
Pooled data from three studies (n = 558)- two recruiting women
to benefit (Analysis 1.5). At later follow-up points, when data were
in healthcare settings (Gillum 2009; McFarlane 2006) and the

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 27
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
only available for the Sullivan 1992 study, the findings suggest that intervention study by Kiely 2010, there was no significant benefit
participants who received advocacy experienced significantly less associated with receiving advocacy-and possibly also CBT for de-
physical abuse than women in the control arm (OR 0.39, 95% CI pression or therapy for smoking/passive smoking (OR 0.96, 95%
0.20 to 0.77; n = 265) at 12 to 24 months follow-up, again with CI 0.44 to 2.12; n = 306; Analysis 2.3).
an NNT of eight, but at three years, the study did not find any
benefit of advocacy (OR 1.07, 95% CI 0.52 to 2.23) (the NNT
for one woman to benefit was 63). Emotional abuse
Best case and worst case scenario analyses estimated the effects of
Six studies measured emotional abuse; five studies evaluated the
missing data on the results of one meta-analysis (Analysis 1.6).
effectiveness of brief advocacy (Gillum 2009; McFarlane 2000;
For the 12-month follow-up data, the results did not change when
McFarlane 2006; Tiwari 2005; Tiwari 2010), and a sixth study
imputing an improved outcome for intervention women who
evaluated an intensive intervention (Sullivan 1992). Tiwari 2005
dropped out of the study (no control group women dropped out)
again measured mean change from baseline, and we obtained the
(OR 0.54, 95% CI 0.29 to 1.01, I² = 0%; n = 192), or when
additional statistical data that we required directly from the study
imputing a poor outcome (OR 0.83, 95% CI 0.46 to 1.49, I² =
investigators. We also obtained additional data from Gillum 2009.
0%; n = 192).
We conducted a meta-analysis of data from three of the five stud-
For descriptive purposes only, two forest plots outline evidence for
ies that offered brief advocacy, two based in healthcare settings
the effectiveness of any type of advocacy (brief or intensive) on
(Gillum 2009; McFarlane 2006) and one which was based within
physical abuse, as assessed using a continuous measure (Analysis
the community (Tiwari 2010). As shown in Analysis 3.1, the in-
1.7) and a dichotomous measure (Analysis 1.8).
dividual study results were inconsistent at up to 12 months fol-
There is insufficient evidence at present to draw unequivocal con-
low-up, but the pooled point estimate indicates that there was no
clusions about the benefits of advocacy, either within healthcare
significant reduction in emotional abuse (SMD − 0.05, 95% CI
settings or within the community, for the reduction of severe phys-
− 0.22 to 0.11, I² = 51%; n = 558; low quality evidence) follow-
ical abuse. One study with low risk of bias suggests that brief advo-
ing the delivery of advocacy. McFarlane 2006 also followed up on
cacy may benefit women suffering minor abuse, but most studies
participants 24 months after the first intervention session (with
did not measure minor abuse. One further study evaluating brief
subsequent sessions being provided every six months); again there
advocacy within the context of a multi-component intervention
was no significant benefit associated with the receipt of advocacy
showed a positive effect immediately upon completion, but there
(SMD − 0.06, 95% CI − 0.28 to 0.16; n = 319; Analysis 3.1).
was no long-term follow-up, and it is not clear if the other com-
In contrast, the antenatal-based study by Tiwari 2005 reported a
ponents (in particular, CBT for depression) also had an impact. It
statistically significant reduction in emotional abuse at 16 to 34
is possible that intensive advocacy can reduce physical abuse one
weeks after receipt of a single, brief session of advocacy (change-
to two years after the intervention but that this effect wanes over
score MD − 4.24, 95% CI − 6.42 to − 2.06; n = 110; moderate
time. The primary studies are underpowered (two of the eight tri-
quality evidence; Analysis 3.2). The fifth trial did not report any
als were pilot studies), and we could only pool data from three brief
standard deviations, nor were these (or alternative relevant data)
interventions and two intensive interventions. The meta-analyses
available from the authors (McFarlane 2000). In the published
were still underpowered, with relatively wide CIs.
paper, however, the authors reported that their analyses showed
no evidence that multiple, brief sessions of advocacy (or advocacy
plus the services of a ’mentor mother’) reduced emotional abuse for
Sexual abuse women recruited in an antenatal setting, in the short or medium
Three studies based in healthcare settings (Gillum 2009; Kiely term.
2010; Tiwari 2005) and one study within the community (Tiwari The one study that provided intensive advocacy to women leaving
2010) evaluated the effect of receiving brief advocacy on subse- shelters, Sullivan 1992, did not show any significant reduction in
quent sexual abuse. (We obtained additional statistical data to emotional abuse at 12 months postintervention-either when this
those reported in the papers of Gillum 2009, Kiely 2010 and was assessed using a continuous measure (MD − 0.02, 95% CI
Tiwari 2010 directly from the study investigators). We conducted − 0.16 to 0.12; n = 265; very low quality evidence; Analysis 3.3)
a meta-analysis on data from two of the studies (Gillum 2009; or using a dichotomous measure (OR 0.58, 95% CI 0.30 to 1.13;
Tiwari 2010) and found that there was no statistically significant n = 141; moderate quality evidence; Analysis 3.4). Similarly, there
reduction in sexual abuse (SMD − 0.12, 95% CI − 0.37 to 0.14, was no evidence of a reduction in emotional abuse as a result of
I² = 44%; n = 239; moderate quality evidence) at up to 12 months receiving advocacy at 24 months follow-up (MD − 0.04, 95% CI
(Analysis 2.1). Tiwari 2005 showed a reduction in sexual abuse − 0.19 to 0.11; n = 265; Analysis 3.3).
in the months following receipt of advocacy, but the CIs included A forest plot (Analysis 3.5) shows the effectiveness of any type
zero: change-score MD − 0.07, 95% CI − 0.30 to 0.16; n = 110; of advocacy (brief or intensive) on emotional abuse, as expressed
moderate quality evidence; Analysis 2.2). In the multi-component using a continuous measure.

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 28
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
With the exception of the two trials by Tiwari and colleagues, there The studies did not show any significant benefit in women receiv-
is little evidence that advocacy reduces or leads to a cessation of ing brief advocacy sessions. The point estimate in Hyman 2001
emotional abuse. This conclusion holds for studies conducted both (Analysis 6.1) favoured the intervention group, but the CIs in-
within and outside of healthcare settings and for studies offering cluded zero (MD − 7.74, 95% CI − 20.33 to 4.85; n = 53; low
either short or more intensive sessions of advocacy. quality evidence).
There was no evidence to suggest that women who received advo-
cacy reported less abuse than women in the control arm at up to
Financial abuse 12 months (SMD − 0.23, 95% CI − 0.53 to 0.08; n = 181; very
No studies reported data for this outcome. low quality evidence; Analysis 6.2) when combining continuous
data from the two intensive advocacy trials (Sullivan 2002; Taft
2011). In addition, there was no evidence that advocacy reduced
Other abuse measures the proportion of women reporting a cessation of abuse (OR 0.72,
95% CI 0.29 to 1.79; n = 103; NNT = 15; very low quality ev-
idence; Analysis 6.3), as reported by the one study that assessed
overall abuse using a dichotomous measure (Taft 2011) .
Risk of homicide
The effectiveness of any type of advocacy (brief or intensive) on
Two studies measured the risk of homicide (Gillum 2009; overall abuse is given in Analysis 6.4.
McFarlane 2006), both recruiting women in healthcare settings
and providing multiple short sessions of advocacy. The authors of
Gillum 2009 provided additional data. Pooled data showed that Psychosocial health
there was no significant reduction in homicide risk (MD 0.13,
Nine of the 13 studies evaluated the effects of advocacy on the
95% CI − 0.54 to 0.80, I² = 0%; 2 studies; n = 358) at up to
primary outcome measures assessing psychosocial health.
12 months, nor did data from McFarlane 2006 (which extended
follow-up to two years) show any reduction in the medium term
(MD − 0.30, 95% CI − 1.07 to 0.47; n = 319; Analysis 4.1).
Quality of life
Six of the trials assessed quality of life. Three of the studies evalu-
ated a brief advocacy intervention; one reported on the two sum-
Risk of work harassment mary component subscales (physical and mental) of the SF-12
McFarlane 2006 measured harassment at work. The two trial arms Health Survey (Tiwari 2010), while the other two trials described
did not differ significantly from each other in the degree of ha- mean changes from baseline for each of the eight subscales com-
rassment experienced at work at 12 months follow-up (MD 0.10, prising the SF-36 measure of quality of life (Cripe 2010; Tiwari
95% CI − 0.36 to 0.56; n = 319), but there was a statistically 2005). Of the three studies evaluating the effectiveness of inten-
significant effect at 24 months that favoured the women in the sive advocacy, one measured quality of life using the two summary
intervention group (MD − 0.60, 95% CI − 0.97 to − 0.23; n = component subscales (physical and mental) of the SF-36 (Taft
319; Analysis 5.1). The study authors did not report this effect as 2011), and two measured overall quality of life (Sullivan 1992;
significant after adjusting significance levels for multiple compar- Sullivan 2002). We obtained additional statistical data directly
isons. from the investigators of four trials (Sullivan 1992; Sullivan 2002;
Taft 2011; Tiwari 2005).
Tiwari 2010, which recruited women from a community centre
and provided brief advocacy over a 12-week period, observed no
Overall abuse significant benefit at six months follow-up either in terms of im-
Three studies reported on overall abuse (physical and emotional proved ’physical’ quality of life (MD 0.80, 95% CI − 1.27 to 2.87;
abuse combined) at up to 12 months follow-up; one evaluated n = 200) or improved ’mental’ quality of life (MD 0.37, 95% CI
a brief session of advocacy for abused women attending an acci- − 1.94 to 2.68; n = 200; Analysis 7.1). Similarly, upon pooling
dent and emergency department (Hyman 2001), and two pro- data from two studies (n = 314) that provided brief, one-off ad-
vided intensive advocacy for women (each within the context of vocacy sessions to pregnant, abused women (Cripe 2010; Tiwari
multi-component interventions) recruited from domestic violence 2005), we found no significant improvements for any of the eight
shelters or social/family service agencies (Sullivan 2002) or from quality of life subscales at three to eight months postintervention:
primary care clinics (Taft 2011). The Taft trial measured overall physical functioning (change-score MD 4.92, 95% CI − 0.32 to
abuse using continuous and dichotomous measures. Authors from 10.16); role physical (change-score MD 7.42, 95% CI − 0.97 to
all three studies supplied additional statistical data to enable us to 15.80); bodily pain (change score MD − 4.51, 95% CI − 10.42
calculate the effect sizes. to 1.39); general health (change-score MD − 0.85, 95% CI −

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 29
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
4.06 to 2.37); vitality (change-score MD − 1.38, 95% CI − 5.56 chotomous measures.
to 2.80), social functioning (change-score MD 0.92, 95% CI − All three trials of brief advocacy followed women for less than 12
5.00 to 6.84); role emotional (change-score MD 9.37, 95% CI months postintervention. We pooled continuous data from two
− 0.31 to 19.05); and mental health (change-score MD − 1.72, of the studies, one of which recruited women from a community
95% CI − 5.31 to 1.87; Analysis 7.2). (N.B. We corrected for centre (Tiwari 2010) and one from a primary care clinic (Gillum
differences in the direction of the mean changes reported in the 2009). As indicated in Analysis 8.1, there was no evidence that
paper by Cripe 2010.) women receiving advocacy reported lower levels of depression than
Taft 2011 trained ’mentor mothers’ to provide up to 12 months women in the control group (SMD − 0.17, 95% CI −0.43 to
intensive advocacy to abused women recruited within primary 0.08, I² = 0%; n = 239). A meta-analysis of dichotomous data from
care clinics (although the intervention was administered in the Gillum 2009 and Tiwari 2005 (both in healthcare settings) showed
community). This study had mixed results (Analysis 7.3): women that significantly fewer women developed depression (NNT = 4)
who received advocacy reported significant improvements in their if they received a brief advocacy intervention (OR 0.31, 95% CI
’physical’ quality of life immediately postintervention (MD 4.90, 0.15 to 0.65, I² = 24%; n = 149; Analysis 8.2).
95% CI 0.98 to 8.82; n = 103), but this did not extend to their Of the three intensive advocacy studies, two recruited women exit-
perceived ’mental’ quality of life (MD 1.90, 95% CI − 2.92 to ing from domestic violence shelters (Sullivan 1992; Sullivan 2002)
6.72; n = 103). Two of the studies conducted by Sullivan and col- and one recruited women from primary care clinics (Taft 2011).
leagues (Sullivan 1992; Sullivan 2002) evaluated the effectiveness All three trials assessed depression using a continuous measure at ≤
of advocacy delivered over a period of 10 to 16 weeks for women 12 months follow-up, and a meta-analysis of these data (Analysis
leaving domestic violence shelters or referred from social and fam- 8.3) revealed no evidence that intensive adequacy reduces depres-
ily service agencies (Analysis 7.4). Both studies reported data at 12 sion (SMD − 0.14, 95% CI − 0.33 to 0.05, I² = 27%; n = 446).
months, and when pooled, data indicated a higher quality of life In this meta-analysis, it should be highlighted that our calculated
for women in the intervention group (MD 0.23, 95% CI 0.00 to mean difference for Sullivan 2002 differs from the statistically sig-
0.46; n = 343). Only one of these two studies followed up par- nificant effect reported by the study investigators, who conducted
ticipants beyond 12 months (Sullivan 1992); data were obtained a multivariate analysis. Only one of these three intensive advocacy
at two years postintervention and again at three years (but only studies measured depression over a longer time period (Sullivan
for the original smaller sample of recruited women). There was no 1992); again, at two years follow-up, there was no evidence that
evidence that intensive advocacy improved quality of life at two receiving advocacy reduced depression among women in the in-
(MD 0.25, 95% CI − 0.02 to 0.52; n = 265) or three years (MD tervention arm (SMD − 0.12, 95% CI − 0.36 to 0.12; n = 265;
0.30, 95% CI − 0.07 to 0.67; n = 124). It is important to note Analysis 8.3). Taft 2011 also assessed the effectiveness of inten-
that these findings differ from the significant effects reported by sive advocacy on depression immediately postintervention using
the study authors. We calculated mean differences based on the a dichotomous measure (Analysis 8.4). The investigators reported
reported raw means and standard deviations, while the study au- no evidence to suggest that there were fewer cases of depression in
thors reported findings based on multivariate analyses (two-year the intervention group: OR 0.51, 95% CI 0.20 to 1.29; n = 103
follow-up) and employed a P < 0.10 significance level to avoid type (with an NNT of 8).
II errors as a result of the smaller sample size (three-year follow- For descriptive purposes only, two forests plot outline the evidence
up). for the effectiveness of any type of advocacy (brief or intensive)
Analysis 7.5 presents a forest plot showing the effectiveness of any on depression, as measured using a continuous measure (Analysis
type of advocacy (brief or intensive) on ’physical’ and ’mental’ 8.5) and a dichotomous measure (Analysis 8.6).
quality of life. Overall, there is inconsistent evidence that advocacy has a ben-
Overall, these studies suggest that brief advocacy is unlikely to eficial impact on depression in abused women. There is limited
improve quality of life in women who have experienced partner evidence that brief advocacy delivered to abused women recruited
abuse. within healthcare settings may help to reduce depression in the
short-term.

Depression
Six studies assessed the effect of advocacy on depression: three Anxiety/psychological distress
evaluated the effect of a brief intervention (Gillum 2009; Tiwari One study measured anxiety as an outcome measure (Sullivan
2005; Tiwari 2010), and three appraised the effect on an inten- 1992), and two other studies measured psychological distress
sive intervention (Sullivan 1992; Sullivan 2002; Taft 2011). We (Constantino 2005; Hyman 2001); as these are similar concepts,
obtained additional statistical data from four of the study inves- we discuss them together. Hyman 2001 appraised a brief advo-
tigators (Gillum 2009; Sullivan 1992; Taft 2011; Tiwari 2005). cacy intervention, while Constantino 2005 and Sullivan 1992
Gillum 2009 assessed depression using both continuous and di- evaluated the effectiveness of intensive advocacy. We analysed

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 30
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Constantino 2005 separately, as it reported mean change from abused women recruited in a healthcare setting. The study authors
baseline. We obtained additional statistical data from authors of supplied all data relating to these outcomes. When followed up
Hyman 2001 and Sullivan 1992. immediately postintervention, there was no evidence that women
For the brief intervention set in an accident and emergency depart- who received advocacy reported less chronic pain (MD − 10.50,
ment (Hyman 2001), there was significant evidence that advocacy 95% CI − 26.78 to 5.78; n = 39; Analysis 10.1) or chronic fatigue
reduced psychological distress at three to four months follow-up (MD − 10.50, 95% CI − 26.81 to 5.81; n = 39; Analysis 11.1)
(MD − 0.56, 95% CI − 1.09 to − 0.03; n = 53; Analysis 9.1). than women in the control arm.
Both intensive interventions recruited women in domestic vio-
lence shelters, but we were unable to pool their findings because
one reported mean change from baseline. As indicated in Analysis Birth outcomes
9.2, Sullivan 1992 reported no statistically significant reduction Kiely 2010 measured birth outcomes following a brief multi-com-
of anxiety associated with the receipt of intensive advocacy at any ponent intervention delivered to pregnant women (advocacy for
time over the following three years: at 12 months (MD − 0.13, abuse and, depending on risk, CBT therapy for depression and
95% CI − 0.35 to 0.09; n = 265), 24 months (MD − 0.01, 95% therapy for smoking or passive smoking cessation/reduction). It
CI − 0.22 to 0.20; n = 265), or 36 months (MD − 0.11, 95% CI is important to note that for the ORs given below, our calculated
− 0.40 to 0.18; n = 124). In the one study that reported change- percentages differ slightly from those reported in the paper. As
from-baseline data (Constantino 2005), the women were only fol- indicated in Analysis 12.1, there was no evidence to suggest that
lowed up immediately postintervention. There was no evidence women who received the intervention were less likely to deliver
that advocacy decreased psychological distress (change-score MD underweight babies as compared with women in the control group
− 35.41, 95% CI − 75.98 to 5.16; n = 24; Analysis 9.3). (N.B. (babies weighing less than 2500 g, n = 306, OR 0.70, 95% CI
In the Constantino trial, the authors reported a statistically signif- 0.36 to 1.37; and babies weighing less than 1500 g, n = 306, OR
icant effect (P value = 0.013) after using a non-parametric test to 0.17, 95% CI 0.02 to 1.41). Similarly, there was no difference
analyse the change from baseline data.) between groups in terms of actual birthweight (MD 41.00, 95%
Analysis 9.4 presents a forest plot showing the effectiveness of CI − 106.19 to 188.19; n = 306; Analysis 13.1), and there was
any type of advocacy (brief or intensive) on anxiety/psychological no evidence to suggest that fewer women who received the inter-
distress. vention had premature births (babies born at 37 weeks gestation:
These studies suggest that brief advocacy offered within healthcare OR 0.65, 95% CI 0.34 to 1.24; n = 306; babies born less than 33
settings may reduce abused women’s feelings of anxiety and psy- weeks gestation: OR 0.22, 95% CI 0.05 to 1.04; n = 306; Analysis
chological distress in the short-term, but it is unknown whether 14.1); this latter result differs from the significant effect (P value =
such a benefit would persist over time. The benefits of offering in- 0.03) reported in the paper. Actual gestational age at delivery did
tensive advocacy to abused women in the community are unclear significantly differ between women in the two arms of the study,
at present. with women who received the intervention delivering babies later
(MD 1.30, 95% CI 0.23 to 2.37; n = 306; Analysis 15.1).
No studies provided data on physical injuries or general measures
Secondary outcomes of physical health.

Physical health Psychosocial health

Death Post-traumatic stress


Two participants died before completion of the studies into which Women who received advocacy in two trials (Gillum 2009; Hyman
they were recruited. In McFarlane 2000, which recruited women 2001) did not significantly differ from women in the control
seeking protection orders, one woman in the control group com- groups in relation to levels of post-traumatic stress (SMD − 0.21,
mitted suicide three weeks into the trial. In Sullivan 1992, which 95% CI − 0.62 to 0.21, I² = 38%; n = 92; Analysis 16.1), accord-
recruited women in domestic violence shelters, one woman in the ing to data provided by the study investigators.
intervention arm was murdered by her partner two weeks into the
trial.
Perceived stress
Data provided by the authors of Hyman 2001 suggests that women
Chronic health disorders who received advocacy had significantly lower levels of perceived
Gillum 2009 measured chronic pain and fatigue; over a three- stress compared with women in the control condition (MD −
month period, it provided multiple sessions of brief advocacy to 0.56, 95% CI − 1.09 to − 0.03; n = 53; Analysis 17.1).

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 31
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Self efficacy social support outcomes (SMD 0.39, 95% CI 0.03 to 0.74; n =
Sullivan 1992 measured self efficacy after intensive advocacy in 124). Constantino 2005 (n = 24) reported finding no effect on
women exiting domestic violence shelters. We obtained additional overall social support following advocacy (using a non-parametric
statistical data relating to this outcome from the study investiga- test), but our analysis (Analysis 20.3) indicates that there was a
tors. At no time point was there evidence that women who received positive effect (change-score MD 10.19, 95% CI 5.67 to 14.71)
advocacy reported higher levels of self efficacy than women in the when the women were followed up immediately postintervention.
control arm. The effect sizes were MD 0.08, 95% CI − 0.19 to Similarly, while the authors reported an improvement only on the
0.35; n = 265 at 12 months follow-up; MD 0.16, 95% CI −0.10 ’belonging’ subscale, our analysis showed significant effects for all
to 0.42; n = 265 at two years follow-up; and MD 0.14, 95% CI four subscales: ’tangible’ (change-score MD 2.19, 95% CI 0.93 to
− 0.22 to 0.50; n = 124 at three years follow-up (Analysis 18.1). 3.45), ’appraisal’ (change-score MD 0.67, 95% CI 0.14 to 1.20),
’self esteem’ (change-score MD 1.14, 95% CI 0.43 to 1.85), and
’belonging’ (change-score MD 4.18, 95% CI 1.18 to 7.18).
Self esteem For descriptive purposes only, Analysis 20.4 presents a forest plot
showing the effectiveness of any type of advocacy (brief or inten-
Sullivan 2002 reported an improvement in self esteem following
sive) on social support.
advocacy (using a multivariate analysis), although our calculated
There are insufficient studies to draw a conclusion about the ben-
effect size shows that this was statistically non-significant (MD
efits of brief advocacy. For intensive advocacy, there is inconsistent
0.26, 95% CI − 0.03 to 0.55; n = 78; Analysis 19.1). These data
evidence that such an intervention improves social support in the
came from the study investigator.
short term. In the long term, intensive advocacy may produce a
positive effect, but this is based on the findings of one small study
Perceived social support in women who actively sought help.

Five of the studies assessed social support: one of these investi-


gated the effect of brief advocacy for abused women recruited at Impact on relationships
a community centre (Tiwari 2010); and four evaluated the effect
of intensive advocacy offered over a prolonged period to women
recruited in or exiting domestic violence shelters, referred from so-
cial and family service agencies (Constantino 2005; Sullivan 1992; Independence from abuser
Sullivan 2002), or attending primary care clinics (Taft 2011). All Sullivan 1991 and Sullivan 1992 measured independence from
of these studies assessed social support using an overall measure, the abuser in women recruited in domestic violence shelters who
but one trial also assessed four separate components of social sup- received weekly sessions of advocacy over a period of 10 weeks.
port (Constantino 2005). This study was also different from the Authors of Sullivan 1992 provided additional statistical data for
others in that the authors assessed mean change from baseline. We one of the studies.
obtained additional statistical data from authors of all four inten- Both trials measured this outcome at up to 12 months follow-up,
sive advocacy studies. and thus we were able to pool the data (Analysis 21.1). We found
There was no evidence that abused women receiving brief advo- no statistically significant, positive, short-term effect (OR 1.22,
cacy in Tiwari 2010 reported higher levels of social support at 95% CI 0.74 to 2.00, I² = 0%; n = 301). Similar results were evi-
six months follow-up compared with women in the control arm dent in Sullivan 1992, the one study that measured independence
(MD 1.60, 95% CI − 0.37 to 3.57; n = 200; Analysis 20.1). It is from the abuser at 12 to 24 months follow-up (OR 1.27, 95% CI
important to note that this calculated effect size differs from the 0.78 to 2.08; n = 261) and at three years (OR 0.97, 95% CI 0.47
statistically significant finding (P value = 0.01) reported by the to 1.98; n = 119).
study authors, who adjusted for baseline differences. The effects of missing data on the results of the one meta-analysis
Three of the intensive advocacy trials reported data from the 12- (n = 330) at 12 months follow-up were estimated via best case and
month follow-up that could be pooled (Sullivan 1992; Sullivan worst case scenario analyses (Analysis 21.2). A best case scenario
2002; Taft 2011). As indicated in the forest plot (Analysis 20.2), (imputing an improved outcome for women in the intervention
there was no evidence to suggest that advocacy had a positive group and a lack of improvement in the control arm) produced a
effect on social support in the short-term (SMD 0.00, 95% CI larger effect size, but the CIs still included no effect (OR 1.58, 95%
− 0.19 to 0.19, I² = 16%; n = 446). Further follow-up data were CI 0.98 to 2.55). Other scenarios also produced non-significant
only available from one of these studies (Sullivan 1992). There results: assumption that missing women in both intervention and
was no evidence that advocacy improved social support at two control groups were independent (OR 1.13, 95% CI 0.71 to 1.80),
years (SMD 0.12, 95% CI − 0.12 to 0.37; n = 265), but by assumption that missing women in the intervention group were
three years (based on the smaller original sample recruited in to still dependent but those in the control arm were independent
the study), there was a clear and significant beneficial effect on (OR 0.82, 95% CI 0.52 to 1.31), and assumption that missing

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 32
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
women in both intervention and control groups were dependent However, there were no statistically significant differences between
(OR 1.13, 95% CI 0.70 to 1.82). the two trial arms for any of the 13 safety behaviours investigated.
These results provide no clear evidence that intensive advocacy for
women who seek refuge in domestic violence shelters helps them
to eventually become independent of their abusers. Resources

Use of resources
Emotional attachment to abuser
The use of resources was measured by four brief advocacy stud-
Sullivan 1992 considered whether intensive advocacy offered to
ies recruiting abused women in healthcare settings: McFarlane
women exiting from domestic violence shelters had a positive effect
2000 employed a summary dichotomous measure of 10 resources,
on their emotional attachment to their abuser. For our analysis,
McFarlane 2006 used a summary continuous measure of a revised
we received additional statistical data from the study investigators.
8-item version, Gillum 2009 used a 15-item measure, and Cripe
As indicated in the forest plot, there was no evidence that abused
2010 reported individual frequency data for 7 items. At protocol
women who received advocacy were any less emotionally attached
stage (Ramsay 2005), we had planned to collect data on partic-
than those in the control arm at up to 12 months (MD − 0.02,
ipants’ use of refuges/shelters, use of counselling, calls to police,
95% CI − 0.08 to 0.04; n = 265), two years (MD 0.00, 95% CI
police reports filed and protection orders sought, as individual
− 0.05 to 0.05; n = 265), or three years (MD − 0.07, 95% CI −
items. However these data were not available in the reported pa-
0.14 to 0.00; n = 124; Analysis 22.1).
pers, which used composite checklists. This means the findings re-
No study reported data on the following outcomes: alcohol or
ported below are based on related but not identical measures. The
drug abuse, attempted suicide or self harm.
resources common to all four studies were domestic violence ser-
vices/battered women’s groups, alcohol/drug treatments, health-
Socioeconomic measures
care, and legal services. Both of the studies by McFarlane and col-
leagues provided multiple, brief sessions of advocacy over a pe-
No study provided data on socioeconomic outcome measures of riod of months and conducted short-term (up to 12 months) and
income, housing, participation in education, or participation in medium-term (12 to 24 months) follow-up. The trial by Gillum
work. 2009 (additional unpublished data provided) also administered
multiple sessions of advocacy (face-to-face and via telephone) over
a three-month period, but follow-up was restricted to immediately
Proxy or intermediate outcome measures
postintervention. Analysis 24.1 presents the effect sizes for the tri-
als using a continuous measure (Gillum 2009; McFarlane 2006).
There was no evidence that advocacy increased resource use: SMD
Use of safety behaviours 0.19, 95% CI − 0.02 to 0.39, I² = 0%; n = 358 at 12 months
Four trials investigated the use of safety behaviours. All studied follow-up; and MD 0.15, 95% CI − 0.07 to 0.37; n = 319 at 24
brief interventions, and three recruited within a healthcare setting months following the first intervention session (with sessions be-
(Cripe 2010; Gillum 2009; McFarlane 2006) while one recruited ing provided thereafter every six months). The study employing a
within the community (Tiwari 2010). Two of the trials reported dichotomous measure (McFarlane 2000) reported no evidence to
(McFarlane 2006; Tiwari 2010) or provided on request (Gillum suggest that advocacy increased the likelihood of resource use over
2009) usable follow-up data. As indicated in Analysis 23.1, pooled and above that found in the control group of women at any time
data from these three studies at ≤ 12 months follow-up showed point, either when advocacy was offered on its own or in combi-
that abused women who received advocacy employed a signifi- nation with the services of a ’mentor mother’. In fact, the opposite
cantly higher number of safety behaviours compared with women occurred, and the likelihood of accessing resources dropped below
receiving usual care (MD 1.39, 95% CI 0.92 to 1.87, I² = 97%; baseline levels in all groups; particularly in the control (from 32%
n = 558). However, this benefit was not apparent in McFarlane to 17%) and advocacy (from 33% to 17%) groups, but also for
2006, the one trial with a two-year follow-up (MD 0.10, 95% CI the group with access to a ’mentor mother’ (from 23% to 21%).
− 0.42 to 0.62; n = 319). We were not able to obtain any usable We were unable to calculate the effect sizes for this trial because of
data for the Cripe 2010 study. The paper reports that when women the baseline differences between the three groups. Cripe 2010 pro-
were followed up 14 to 28 weeks postintervention, there was an vided frequency data on the use of individual resources following
increase in the number of women in the intervention group who a 30-minute advocacy session. The authors report that there were
adopted 8 of the 13 safety behaviours (range 1.8% to 30.3%); this no statistically significant differences in the type of community
contrasts with a smaller increase of women in the control group resource accessed by the women in the two trial arms 14 to 28
who adopted four of the safety behaviours (range 0.5% to 11.2%). weeks postintervention, but they did not provide test values. The

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 33
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
results from these four trials suggest that brief advocacy has mini- over a 10-week period. However, Sullivan 1991 did not report
mal effect on subsequent resource use by abused women recruited any means or standard deviations, nor did the authors make them
in healthcare settings. available. Findings from Sullivan 1992 were mixed. There was no
evidence to suggest that abused women who received advocacy ex-
perienced fewer difficulties in accessing resources when compared
with women in the control arm, either at 12 months follow-up
Difficulty in accessing resources
(MD − 0.01, 95% CI − 0.16 to 0.14; n = 265) or at three years
The difficulty that women experienced in accessing resources was (MD − 0.12, 95% CI − 0.33 to 0.09; n = 124). However, at
measured using a composite 11-item measure (housing, material the two-year follow-up, there was a benefit associated with receiv-
goods and services, education, employment, healthcare, child care, ing advocacy (MD − 0.18, 95% CI − 0.34 to − 0.02; n = 265;
transportation, social support, legal assistance, financial issues, and Analysis 25.1). Based on the findings of this one trial, at present
issues regarding the children). Where participants had not directly there is insufficient evidence to indicate whether intensive advo-
tried to access a resource, they were asked to answer how difficult cacy does or does not decrease difficulties in accessing resources.
they expected it would be. No study included in this review reported data on the use of
Sullivan 1991 and Sullivan 1992 assessed this outcome, the lat- refuges/shelters; the use of counselling; calls to police; police re-
ter providing additional data on top of what they reported in ports filed; protection orders sought; and maintenance of family
their papers. Both studies recruited women exiting a domestic ties (i.e. children staying with mother).
violence shelter and provided intensive weekly advocacy sessions

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 34
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
intimate partner abuse (Review)
Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience A D D I T I O N A L S U M M A R Y O F F I N D I N G S [Explanation]

Brief advocacy interventions for women who experience intimate partner abuse versus usual care at up to 12- month follow- up

Patient or population: wom en with intim ate partner abuse


Settings: within or outside of healthcare settings
Intervention: brief advocacy interventions

Outcomes Illustrative comparative risks* (95% CI) No. of participants Quality of the evidence Comments
(studies) (GRADE)

Assumed risk Corresponding risk

Control Brief advocacy interven-


tions

Physical abuse The m ean physical abuse The m ean physical abuse 558 ⊕⊕⊕ Gillum 2009; M cFarlane
Outcom e was m easured on ranged across control in the intervention groups (3 studies) M oderate b 2006; Tiwari 2010
dif f erent scales in dif f erent groups f rom 0.45 to 12.6 was 0 standard deviations
studies a higher
Follow-up: im m edi- (0.17 lower to 0.16 higher)
ately postintervention to 12
m onths

Physical abuse by severity The m ean physical abuse The m ean physical abuse 110 ⊕⊕⊕ Tiwari 2005
- severe by severity - severe in the by severity - severe in the (1 study) M oderate d
Conf lict Tactics Scales control groups was 0.17 intervention groups was 0.
(CTS) m ean change f rom 08 higher
baseline (0.26 higher to 0.42 higher)
Follow-up: 16 to 34 weeks c

Sexual abuse The m ean sexual abuse The m ean sexual abuse in 239 ⊕⊕⊕ Gillum 2009; Tiwari 2010
CTS and Partner Abuse ranged across control the intervention groups was (2 studies) M oderate f,g
Scale (PAS) e groups f rom 0.10 to 0.14 0.12 standard deviations
Follow-up: im m edi- lower
ately postintervention to 12 (0.37 lower to 0.14 higher)
m onths
35
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
intimate partner abuse (Review)
Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience

Sexual abuse The m ean sexual abuse in The m ean sexual abuse in 110 ⊕⊕⊕ Tiwari 2005
CTS sexual abuse single- the control groups was − 0. the intervention groups was (1 study) M oderate h,i
item m ean change f rom 06 0.07 lower
baseline (0.30 lower to 0.16 higher)
Follow-up: 16 to 34 weeks c

Emotional abuse The m ean em otional abuse The m ean em otional abuse 558 ⊕⊕ Gillum 2009; M cFarlane
Outcom e was m easured on ranged across control in the intervention groups (3 studies) Lowb,k 2006; Tiwari 2010
dif f erent scales in dif f erent groups f rom 12.11 to 24.80 was 0.05 standard devia-
studies j tions lower
Follow-up: im m edi- (0.22 lower to 0.11 higher)
ately postintervention to 12
m onths

Emotional abuse The m ean em otional abuse The m ean em otional abuse 110 ⊕⊕⊕ Tiwari 2005
CTS m ean change f rom in the control groups was − in the intervention groups (1 study) M oderate i
baseline 1.92 was 4.24 lower (6.42 lower
Follow-up: 16 to 34 weeks c to 2.06 lower)

Overall abuse The m ean overall abuse in The m ean overall abuse in 53 ⊕⊕ Hym an 2001
Index of Spouse Abuse the control groups was 23. the intervention groups was (1 study) Lowl,m
(ISA) score. Scale f rom 0 to 39 7.74 standard deviations
30 lower
Follow-up: 3 to 4 m onths (20.33 lower to 4.85 higher)

* The basis f or the assumed risk (e.g. the m edian control group risk across studies) is provided in f ootnotes. The corresponding risk (and its 95% CI) is based on the assum ed
risk in the com parison group and the relative effect of the intervention (and its 95% CI).
CI: conf idence interval; GRADE: Grades of Recom m endations, Assessm ent, Developm ent, and Evaluation

GRADE Working Group grades of evidence


High quality: Further research is very unlikely to change our conf idence in the estim ate of ef f ect.
M oderate quality: Further research is likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and m ay change the estim ate.
Low quality: Further research is very likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and is likely to change the estim ate.
Very low quality: We are very uncertain about the estim ate.
a Partner
Abuse Scale (PAS), physical subscale; 46-item Severity of Violence Against Wom en Scale (SVAWS), physical violence
subscale; Chinese version of the 39-item Revised Conf licts Tactics Scale (CTS), psychological aggression subscale.
36
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
intimate partner abuse (Review)
Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience
b One study has signif icant biases, one has m oderate bias, and one no signif icant bias.
c6 weeks post-delivery, but representing 16 to 34 weeks postintervention.
d Dif f erence f rom severe abuse results are consistent with abuse severity ef f ects; in this study, advocacy is less ef f ective

when the abuse is m ore severe.


e
Conf lict Tactics Scale, sexual coercion subscale; PAS, sexual abuse subscale.
f There is m oderate overlap in CIs and m oderate heterogeneity.
g Sam ple size less than 400.
h The low ef f ect size is consistent across studies.
i Total events greater than 300.
j Partner Abuse Scale (PAS), non-physical subscale, score range 0 to 25; 46-item SVAWS, Chinese version of the 39-item

revised CTS, psychological aggression subscale.


k There is inconsistency between results, though this is partly explained by setting with one study in the com m unity and two in

healthcare settings.
l Attrition and contam ination bias, also insuf f icient inf orm ation to determ ine whether there was allocation concealm ent.
m Sm all sam ple size (less than 400), standard deviation (SD) greater than 0.5
37
DISCUSSION utes up to 80 hours), the between-study differences in staff deliv-
ering the advocacy (paraprofessional students, nurses, professional
advocates, psychologists, social workers, community health work-
ers, trained ’mentor mothers’, and study investigators), the wide
Summary of main results range of outcomes reported (25 different outcomes), the meth-
This review identified 11 randomised controlled trials (RCTs) and ods used to assess these outcomes (continuous or dichotomous
2 quasi-RCTs (reported in 21 papers) that examined the effective- measures), and their observed effects. Three of the trials differed
ness of advocacy interventions conducted within healthcare set- in that they evaluated multi-component interventions in which
tings (8 studies) and in the community (5 studies), for women advocacy was one of several components. The duration of follow-
who had experienced intimate partner abuse. The studies recruited up also varied across studies and ranged from immediately postin-
2141 participants. The concept of empowerment was integral to tervention to three years. This heterogeneity meant we could only
the interventions, as was the belief that the help provided should perform a limited number of meta-analyses. The remainder of the
be tailored to meet the wants and needs of the individual women. syntheses are in narrative form.
However, the primary studies had considerable heterogeneity in We have summarised results in two logic models, one for brief
terms of the intensity of the advocacy offered (from about 30 min- advocacy (Figure 4) and one for intensive advocacy (Figure 5).

Figure 4. Logic model summarising results for brief advocacy interventions.

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 38
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Figure 5. Logic model summarising results for intense advocacy interventions.PTSD: Post Traumatic Stress
Disorder.

Overall, we found equivocal evidence that advocacy reduces or


leads to a cessation of abuse. There was evidence from two studies follow-up in an antenatal setting but not in other settings. Aside
with moderate risk of bias that brief advocacy administered in an- from the one study with positive findings, four other trials of
tenatal care may reduce physical abuse at up to 12 months follow- brief advocacy showed no positive effect on emotional abuse (three
up, but in one of these the benefit was limited to minor physical recruiting within healthcare and one in the community). The one
abuse. The other study had only immediate postintervention fol- study of intensive advocacy also failed to demonstrate any benefit.
low-up, and nearly two-thirds of the abused women (62%) would There is low to very low quality evidence indicating that both
also have received CBT for depression in addition to advocacy. brief and intensive advocacy slightly reduce overall abuse; the con-
There is moderate to low quality evidence for a lack of effect of fidence intervals either include zero or cross the line of no effect.
brief advocacy in reducing physical abuse (severity undifferenti- In summary, there were no differences between the intervention
ated) in other settings and designs at up to 12 months follow-up. and control arms of the primary studies for the majority of abuse
There is low to very low quality evidence that there is a marginal outcomes, none of the evidence was of good quality, and data from
reduction in physical abuse from intensive advocacy at up to 12 most of the studies for most of the abuse outcomes could not be
months follow-up. However, the two trials of intensive advocacy pooled to increase the power of the analyses.
in women recruited in domestic violence shelters/refuges had a Studies measuring other primary psychosocial outcomes showed
high risk of bias. One of these studies had medium term follow- some benefit for advocacy but, as with abuse measures, evidence
up and reported that intensive advocacy increased the cessation of was not good quality, and benefits were not consistent across stud-
physical abuse in women exiting a shelter at 12 to 24 months. ies and settings. There was evidence that brief advocacy improves
There is moderate quality evidence that brief advocacy has no depression in abused women attending healthcare facilities and
effect in reducing sexual abuse at up to 12 months follow-up. that psychological distress may decrease when abused women at-
The evidence for brief or intensive advocacy reducing emotional tending a hospital emergency department receive a brief session
abuse is inconsistent. There is moderate-to-low quality evidence of advocacy. However, these findings were based on only three
that brief advocacy reduces emotional abuse at up to 12 months studies, and there was no evidence that the effect persisted over

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 39
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
time. Neither of the two intensive studies reported an effect on rural settings. Most of the women were recruited because they
psychological distress. There was no reduction in depression asso- were experiencing current physical or sexual abuse (within the last
ciated with intensive advocacy, and no benefit in terms of reducing 12 months), although seven studies also included women experi-
anxiety/psychological distress, though the quality of the data was encing physical, sexual or emotional abuse. The majority of the
weak. The three trials of brief advocacy that measured the effect participants were married or still in contact with the perpetrator
on quality of life suggested that there was no benefit. In contrast, at study entry. The age range of participants was wide (15 to 65
there was some low quality evidence that intensive advocacy may years). Most of the women were of lower socioeconomic status.
improve abused women’s quality of life in the short term: two stud- There was ethnic diversity across many of the trials (whites, African
ies assessed overall quality of life in women recruited from domes- Americans and Latinas), but five studies were ethnically exclusive
tic violence shelters/refuges and reported an improved ’physical’ (African American, Latina and Chinese) or near exclusive (Mes-
quality of life (but no equivalent in perceived ’mental’ quality of tizo).
life) when women were recruited in primary care settings. From the available evidence, we cannot say whether the interven-
In terms of secondary outcomes, once again the findings are mixed. tions had similar effects on women experiencing different types
There is evidence that brief advocacy leads to more safety be- of abuse. Many of the women recruited into the studies reported
haviours being practiced in the short-term, but in the long-term severe physical abuse, so it is possible that advocacy is acceptable to
(and based on results from a single study) this benefit is no longer women who are at high risk of further physical and sexual abuse.
apparent. Brief advocacy improved perceived anxiety/psycholog- However, there is also some evidence that advocacy may be more
ical distress in one trial set in a hospital emergency department. effective with less severe physical abuse. It is not known if advo-
Similarly, abused women receiving brief advocacy within an ante- cacy is acceptable to women experiencing other forms of intimate
natal setting delivered babies with higher gestational ages; however, partner abuse, although one of our included studies (Tiwari 2010)
no other benefits in birth outcomes were reported. The findings recruited women from a community centre who were primarily
for social support were equivocal; in particular there was contra- experiencing psychological abuse. In terms of differential effects
dictory evidence about whether abused women report improved related to where a woman is in the abuse trajectory, we do not know
support following intensive advocacy. It remains unclear if advo- whether women actively seeking help (such as those recruited in
cacy can help women to remain independent of their abusers or to shelters or refuges) might benefit more or less from advocacy than
emotionally detach from their abuser. Similarly, there was no evi- women who have just disclosed abuse, such as those recruited in a
dence to suggest that advocacy improves chronic pain and fatigue, healthcare setting. We cannot resolve that question based on the
self efficacy, self esteem, or post-traumatic stress disorder, or that included studies, as there was no consistent difference in benefits
women receiving advocacy are more likely to access community for different outcomes between settings. There was also little evi-
resources. dence available to show if advocacy interventions were any more
Taken as a whole, we conclude that brief or intensive advocacy or less effective amongst people from different ethnic groups. The
administered to abused women may improve a wide range of out- urban setting common to all of the studies prevents us from draw-
comes, but the magnitude and consistency of these benefits are ing any conclusions about the effectiveness of advocacy interven-
still uncertain. The positive findings of one antenatal study with tions for abused women residing in rural locations.
low risk of bias were striking in that the provision of a one-off It was not possible to determine what aspects of advocacy interven-
session of advocacy led to a reduction in minor physical abuse, tions were the most or the least effective, as none of the included
emotional abuse, and post-natal depression (Tiwari 2005). How- studies considered this question, and there were not enough studies
ever, the overall findings from the remaining 12 trials were mixed, to pool for any outcome for meta-regression analysis. Neither were
reflecting the lack of power of the primary studies. Unfortunately, we able to reach any conclusions about the potential additional
the heterogeneity of interventions and outcomes measured across impact on outcomes from the studies that were multi-component
the studies precluded the pooling of many results and an estimate in content (i.e. which offered components other than advocacy to
of the magnitude of the overall effect. Where meta-analysis was abused women, their children, or both), as there were insufficient
possible, we were only able to pool a maximum of three studies. studies to conduct a subgroup analysis.
For these reasons, the present findings are not conclusive with re- One study did not lose any participants over time (Tiwari 2010),
gards to the benefits of advocacy. while another lost nearly half (48%) of its sample (Hyman 2001).
The other 11 trials all retained at least 73% of their recruited
Overall completeness and applicability of
sample.
evidence
The studies included in this review were conducted on women
recruited in a variety of settings, with eight studies based in health- Quality of the evidence
care organisations. However, most took place in developed, in-
dustrialised countries, and none of the trials were carried out in Only one trial was assessed to have low risk of bias in all the crite-
ria considered (Tiwari 2005). Four of the studies provided insuf-

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 40
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
ficient detail to confidently ascertain whether they complied with and assessment of risk of bias and outcome quality, and another
at least four of the eight ’Risk of bias’ criteria. In six trials, there checked data extraction.
were insufficient details about the method of sequence generation,
and in five of the studies it was not clear if allocation concealment
was maintained (in a further three studies, this was compromised). Agreements and disagreements with other
Four studies did not give sufficient information on whether the studies or reviews
outcomes measures were assessed blindly (and a further four were This review broadly concurs with the findings of previous re-
not blinded). Seven did not provide full details on the complete- views of advocacy interventions (Abel 2000; Feder 2009; Hender
ness of their data or else had attrition that was significantly dif- 2001; Klevens 2004; Nelson 2004; Ramsay 2002; Ramsay 2005a;
ferent between groups. Eight of the studies did not discuss what Wathen 2003) and the review on which the WHO guidelines
steps, if any, were taken to prevent women in the control group (WHO 2013b) are based, although by restricting ourselves to
from receiving components of the intervention (and a further three RCTs and quasi-RCTs, we have excluded studies that were in-
reported that this was compromised). We were unable to attribute cluded in some of the other reviews. Hence, we were more con-
differences in effect sizes for any given outcome to the risk of bias. servative in our judgement of the effectiveness of advocacy. How-
Taken as a whole, we conclude that the present evidence for the ever, by increasing the number of identified RCTs and quasi-RCTs
effectiveness of advocacy is undermined because of difficulties in and calculating effect sizes for most of the outcomes reported in
assessing the risk of bias for most trials in the review. Future reports the included studies, we have extended the findings of earlier re-
of advocacy interventions should include full details on how the views. Previous reviews have reported the findings as reported by
studies have been conducted, thereby allowing for the risk of bias the individual study authors. By calculating the effect sizes (mean
to be determined. or SMD and OR) we were able to compare across studies. We
When considering the data in terms of GRADE for abuse out- have also highlighted some discrepancies between results reported
comes at ≤ 12 months follow-up, the quality of evidence for most as statistically significant and the effect sizes as calculated by our
abuse outcomes from intensive advocacy was rated as very low, in team. Generally we concur that, while there is some evidence that
all cases because of a combination of risk of bias and imprecision. advocacy in health or community settings can reduce further abuse
All studies lost GRADE points because of imprecision, which was and improve psychosocial outcomes of women experiencing part-
judged to occur with continuous measures when the sample size ner abuse, there are too few studies studying the same interven-
was less than 400, the standard deviation was greater than 0.5, or tion and measuring the same outcomes over a reasonable period
both, and with dichotomous measures when the results crossed of time to draw any firm conclusions about the magnitude of the
the line of no effect, the total number of outcome events was less benefit or the populations most amenable to the interventions.
than 300, or both. This highlights the need for larger studies; four
of the studies in this review were pilots, which may partly also
explain the high risk of bias.
Using GRADE, we found that the quality of the evidence for abuse
AUTHORS’ CONCLUSIONS
outcomes for brief advocacy was higher, though still poor; the evi-
dence was assessed as moderate to low, with none being considered
very low quality. Reasons were mixed, with five rated as moderate Implications for practice
because of imprecision issues, one because of indirectness, and one Our results suggest that the existing body of research evidence has
because of risk of bias; three outcome results were graded as low not fully established the potential benefits of advocacy (either of-
quality. fered as a brief or more intensive intervention), including cessation
or reduction of abuse, improved quality of life, and reductions in
depression and anxiety.
Potential biases in the review process We do not believe that the weak evidence for advocacy as an in-
We believe that our review process identified all RCTs and quasi- tervention for intimate partner abuse means that existing services
RCTs on advocacy interventions for women experiencing partner should be withdrawn. The evidence has actually strengthened with
abuse published up to the censor date. We also obtained a copy of the results of recent trials, and we await the findings of new studies
an unpublished PhD thesis that evaluated an advocacy interven- of advocacy within and outside of healthcare settings. The weak-
tion. We obtained additional data from all but one of the study ness of the current evidence base means that we cannot adequately
authors that we contacted. Likewise, the majority of trialists re- judge their effectiveness, not that advocacy interventions are nec-
sponded to our request to inform us of any other trials that we essarily ineffective. The largely positive point estimates for most
may have missed. Other experts in this field also responded to our of the outcomes in all of the studies may not be a firm basis for
request asking if they knew of any additional trials. Two review systematically extending advocacy to healthcare settings, but they
authors independently made decisions about inclusion of studies should encourage further evaluation of advocacy’s role in these

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 41
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
settings, including routine monitoring of outcomes for women Finally, economic analyses are required to ascertain if the resources
receiving advocacy. devoted to advocacy interventions are cost-effective in healthcare
and community settings.
Implications for research
Further research is required to determine the effect of advocacy
interventions for abused women in a number of areas. In this re-
spect-and in keeping with our earlier review-we make the follow- ACKNOWLEDGEMENTS
ing recommendations. The original review was peer-reviewed by three Editors of the
Cochrane Developmental, Psychosocial and Learning Problems
First, there is a need for more trials of advocacy interventions in a
Group (including the Statistics Editor) and four external peer re-
variety of settings, particularly in healthcare settings. We know that
viewers, one of whom had consumer expertise. We are grateful to
women experiencing partner violence present frequently to health
the Review Group Editors and staff, particularly to our Co-ordi-
services and require wide-ranging medical services (Campbell
nating Editor (Professor Geraldine Macdonald), Managing Edi-
2002; Davidson 2001), and that abused women themselves iden-
tor (Jane Dennis), and Trials Search Coordinator (Jo Abbott) for
tify primary care clinicians as appropriate people from whom to
their input. We thank the included study authors who responded
seek help and assistance (Feder 2006b). However, while the num-
to our queries (Deborah Bybee, Kelly Hyman; Renee McDon-
ber of such studies has increased, we still found only one study
ald, Judith McFarlane), supplied additional data (Deborah By-
conducted in an accident and emergency care setting, two based
bee, Rose Constantino, Kelly Hyman, Agnes Tiwari), and checked
in primary care/public health clinics and mother and child clinics,
our list of included studies for omissions (Deborah Bybee, Rose
and four in antenatal clinics.
Constantino, Kelly Hyman, Renee McDonald, Judith McFarlane,
Second, we need debate over which outcomes should be measured Agnes Tiwari). We thank Jeanne Trifone who responded to our
in advocacy trials. The studies included in this review examined query about whether one of her studies fulfilled our inclusion cri-
a wide range of outcomes. However, it is questionable whether teria. We would also like to thank members of Domus Medica,
all of these might be expected to change as a result of receiving the Medical Research Council (MRC) Gender and Health Unit,
advocacy. For example, the outcome ’independence from abuser’ and other experts and colleagues for checking our list of included
is not necessarily a desirable outcome from the survivor’s point of studies for omissions. In particular, our thanks go to Carmen Fer-
view, although it is legitimate in that there is a subgroup of women nandez Alonso, Rachel Jewkes, Sylvie Lo Fo Wong, Davorina Pe-
who report that they want to leave the relationship (McFarlane tek, Susana Sanchez, Lynne Stevens, and Steffi Winter. Finally, we
2013 [pers comm] in McFarlane 2000). Trials need to examine a wish to acknowledge the contribution made to the original review
smaller range of outcomes, and these should be measured using by two of its past co-authors: Yvonne Carter (now sadly deceased)
more standardised scales. This will require consensus among re- and Alison Warburton.
searchers in this field. The updated review was peer-reviewed by three Editors of the
Cochrane Developmental, Psychosocial and Learning Problems
Third, more evidence is needed from trials where the participants
Group (including the Statistics Editor) and two external peer re-
are followed up for years, rather than weeks or months. Data on
viewers, one of whom had consumer expertise. We are grateful to
long-term outcomes are essential since some effects are likely to
the Review Group Editors and staff, particularly to our Co-ordi-
attenuate over time and others may not emerge until years after
nating Editor (Geraldine Macdonald), Managing Editor (Joanne
an intervention has ended.
Wilson), Former Managing Editor (Laura MacDonald), Assistant
Fourth, trials need to test theoretically explicit interventions to Managing Editor (Gemma O’Loughlin), and Trials Search Co-
determine what works (or does not work) for whom, when, and ordinator (Margaret Anderson). We would like to thank all the
in what contexts. In particular, interventions should take into ac- authors who responded to our queries (Swee May Cripe, Michele
count the stages that abused women go through in dealing with Kiely, Angela Taft, and Nancy Woods), those who supplied ad-
their situation (Hegarty 2010; Zink 2004). ditional data (Michele Kiely, Angela Taft, and Nancy Woods),
and those who checked our list of included studies for omissions
Fifth, further work is needed to ascertain how advocacy interven- (Dawn Bybee, Swee May Cripe, Michele Kiely, Chris Sullivan,
tions can be tailored to cultural variations between ethnic groups Angela Taft, Agnes Tiwari). We would also like to thank authors
(Rodriguez 2006) and for abused women living in rural commu- who responded to queries about whether their studies fulfilled
nities, resource poor settings, or both. In the development of the our inclusion criteria or who provided us with additional infor-
WHO guidelines on the healthcare response to intimate partner mation (Megan Bair-Merritt, Ann Coker, Marilyn Ford-Gilboe,
violence and sexual abuse (WHO 2013c), applying the evidence Karin Grip, Kelsey Hegarty, Renee McDonald, Elizabeth Miller,
on advocacy outside of resource-rich countries was problematic. Andrew Parcy, Agnes Tiwari). Lastly, we thank members of an in-

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 42
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
formal network of European primary care domestic violence re-
searchers and other experts and colleagues for checking our list
of included studies for omissions. In particular, our thanks go to:
Loraine Bacchus, Claudia Garcia Moreno Esteva, and Charlotte
Watts.

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Tiwari 2010 {published data only} Interpersonal Violence 2012;27(10):1911–31.
Tiwari A, Fong DY, Wong JY, Yuen KH, Yuk H, Pang P, Witte SS, Altantsetseg B, Aira T, Riedel M, Chen J, Potocnik
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clinical trial. AIDS and Behavior 2011;15(8):1785-94. randomized controlled trial. Obstetrics and Gynecology
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Casey RL, Berkman M, Stover CS, Gill K, Durso S, El-Mohandes 2011 {published data only}
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Journal of Psychological Trauma 2007;6(1):39–49. integrated behavioral intervention: a randomized controlled
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risk for abuse. Journal of Obstetric, Gynecologic and Neonatal
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AR. The impact of victim-focused outreach on criminal a report of a local pilot project. South Dakota Journal of
legal system outcomes following police-reported intimate Medicine 2002;55(4):147–9.
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The impact of community-based outreach on psychological F, Shehzad S. Testing a community derived intervention to
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Dichter 2012 {published data only} Houry 2011 {published data only}
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violence. Violence Against Women 2012;18(1):44–63. inner-city emergency department. Emergency Medicine
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TL, Campbell JC, et al. Use of online safety decision Humphreys J, Tsoh JY, Kohn MA, Gerbert B. Increasing
aid by abused women: effect on decisional conflict in a discussions of intimate partner violence in prenatal care
randomized controlled trial. American Journal of Preventive using Video Doctor plus Provider Cueing: a randomized,
Medicine 2015;48(4):372-83. [PUBMED: 25547929] controlled trial. Womens Health Issues 2011;21(2):136–44.
El-Mohandes 2008 {published data only} Jack 2012 {published data only}
El-Mohandes AAE, Kiely M, Joseph JG, Subramanian S, Jack SM, Ford-Gilboe M, Wathen CN, Davidov DM,
Johnson AA, Blake SM, et al. An intervention to improve McNaughton DB, Coben JH, et al. Development of a nurse
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home visitation intervention for intimate partner violence. intervention to mitigate domestic violence among young
BMC Health Services Research 2012;12:50. Indian women: the Dil Mil trial. BMC Public Health 2012;
James 2014 {published data only} 12:943.

James JP, Taft A, Amir LH, Agius P. Does intimate partner Krishnan S, Subbiah K, Khanum S, Chandra PS,
violence impact on women’s initiation and duration of Padian NS. An intergenerational women’s empowerment
breastfeeding?. Breastfeeding Review 2014;22(2):11–9. intervention to mitigate domestic violence: results of a pilot
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Johnson 2011 {published data only} (3):346–70.
Johnson DM, Zlotnick C, Perez S. Cognitive behavioral Kyegombe 2014 {published data only}
treatment of PTSD in residents of battered women’s shelters: Kyegombe N, Abramsky T, Devries KM, Starmann E,
results of a randomized clinical trial. Journal of Consulting Michau L, Nakuti J, et al. The impact of SASA!, a
and Clinical Psychology 2011;79(4):542–51. community mobilization intervention, on reported HIV-
Jouriles 2001 {published and unpublished data} related risk behaviours and relationship dynamics in

Jouriles EN, McDonald R, Spiller L, Norwood WD, Kampala, Uganda. Journal of the International AIDS Society
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among children of battered women. Journal of Consulting Lindsay 2013 {published data only}
and Clinical Psychology 2001;69(5):774–85. Lindsay M, Messing JT, Thaller J, Baldwin A, Clough A,
McDonald R, Jouriles EN, Skopp NA. Reducing conduct Bloom T, et al. Survivor feedback on a safety decision aid
problems among children brought to women’s shelters: smartphone application for college-age women in abusive
intervention effects 24 months following termination of relationships. Journal of Technology in Human Services 2013;
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1999. McFarlane J, Malecha A, Gist J, Watson K, Batten E, Hall
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partner violence intervention. Journal of Interpersonal
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McKean L. Self-sufficiency and safety: the case for onsite
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Krasnoff M, Moscati R. Domestic violence screening and partner violence intervention to reduce risk associated with
referral can be effective. Annals of Emergency Medicine 2002; reproductive coercion. Contraception 2011;83(3):274–80.
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of Orthopsychiatry 2014;84(4):321–8. [PUBMED: Simmons 2011 {published data only}
24999518] Simmons CA, Farrar M, Frazer K, Thompson MJ. From
the voices of women: facilitating survivor access to IPV
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intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
CHARACTERISTICS OF STUDIES

Characteristics of included studies [ordered by study ID]

Constantino 2005

Methods Randomisation method: a permuted block randomisation with a 1:1 ratio


Analysis by intention-to-treat: no
Power calculation: no

Participants Setting: recruited in domestic violence shelter


Country: USA
Inclusion criteria: none stated explicitly but women were first-time residents of a DV
shelter
Exclusion criteria: none stated
Numbers recruited: 30 (15 intervention group, 15 control group)
Number of dropouts: 6 (2 intervention group, 4 control group)
Numbers analysed (and percentage of recruited): 24 (13 (87%) intervention group, 11
(73%) control group)
Age: mean 35 years (range 28 to 43 years)
Ethnicity: 71% white, 29% black
Socioeconomic status indicators (annual household income): 58% < USD 10,000,
17% USD 10,000 to USD 19,999, 21% USD 20,000 to USD 29,999, 4% > USD 30,
000
Education background: 12% up to junior high, 67% up to high school, 4% up to trade
school, 17% up to degree

Interventions Intervention
1. A structured group social support intervention (SSI) to provide and include
information on resources, hours of operation to access these, and an environment in
which to chat with counsellor (trained nurse) and friends (usual shelter care also
provided)
2. Eight weekly sessions of 90 minutes duration
Control
No treatment control (NTC): usual shelter care and unstructured chats with the principal
investigator

Outcomes 1. Interpersonal Self Evaluation List (ISEL) - social support total score and four
subscales (belonging, tangible, appraisal, self-esteem)
2. Brief Symptom Inventory (BSI) - psychological distress
(healthcare utilisation also measured but not relevant to the review)
Timing of follow-up: immediately postintervention only

Notes Funded by the University of Pittsburgh Central Research Development Fund


Data were collected for the study between July 2003 and June 2004

Risk of bias Risk of bias

Bias Authors’ judgement Support for judgement

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 55
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Constantino 2005 (Continued)

Random sequence generation (selection Unclear risk Randomisation after baseline data collec-
bias) tion using a permuted block randomisation
scheme with a ratio of 1:1. No other infor-
mation was provided

Allocation concealment (selection bias) Unclear risk The medical advocate directed recruitment
and retention, but there was no informa-
tion about who performed the allocation
or the procedure used

Blinding (performance bias and detection Unclear risk Blinding of participants and key person-
bias) nel (person providing the intervention) was
All outcomes not possible. No information on blinding
for outcome assessment was provided

Incomplete outcome data (attrition bias) High risk Large difference between groups: 2/15
All outcomes (13%) missing from intervention group;
4/15 (27%) missing from control group.
Reasons given for attrition (difficulties with
transportation, living conditions, child care
issues) were not reported by trial arm; some
may be secondary to being in a particular
arm (e.g. not having advocacy)

Selective reporting (reporting bias) Low risk In the paper, full statistical data were only
reported for the significant findings while
other outcomes were only mentioned as
being near-significant or non-significant.
These missing data were subsequently pro-
vided by the investigators

Baseline measurement of outcome mea- Low risk No specific information on between-group


sures differences was provided, although the
means and standard deviations seemed
comparable. (Study investigators calculated
mean change from baseline scores)

Reliability of outcome measures Low risk Outcome measures were reliable

Protection against contamination Unclear risk There might have been communication
between women in different arms of the
trial. Also, some participants in the control
group had the opportunity to talk with the
principal investigator, although not with
the person delivering the advocacy inter-
vention. This may have had an effect, but
would, if anything, have diminished any
positive effects

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 56
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cripe 2010

Methods Randomisation method: a randomised block design


Analysis by intention-to-treat: no
Power calculation: no

Participants Setting: public hospital prenatal clinic


Country: Peru
Inclusion criteria
1. Prenatal care patients (12 to 26 weeks gestation)
2. Aged 18 to 45 years
3. Spoke and understood Spanish
4. Screening positive for intimate partner violence in past 12 months
Exclusion criteria: none stated
Numbers recruited: 220 (110 intervention group, 110 control group)
Number of dropouts: 16 (6 intervention group, 10 control group)
Numbers analysed (and percentage of recruited): 204 (104 (95%) intervention group,
100 (91%) control group)
Age: mean 26 years intervention group, 27 years control group
Ethnicity: 87% Mestizo
Socioecomomic status indicators: 63% unemployed, 51% limited access to basic foods,
64% limited access to medical care
Education background: 54% ≤ 6 years; 11% 7 to 12 years; 34% > 12 years

Interventions Intervention
One-on-one empowerment counselling provided by trained hospital-based social work-
ers: empathic listening and acknowledgement of woman’s perceptions and feelings, sup-
portive counselling and education (including helping women to understand the cycle
of violence), advice in areas of safety (including a review of safety plan components and
an appraisal of the safety of adopting each behaviour), provision of a 13-item safety
plan brochure (as well as other prenatal brochures on other topics), a list of community
resources (such as emergency shelter, legal aid, law enforcement, and counselling) and
what to expect when seeking help from these services, and advice on strategies for seek-
ing help (including assistance with telephone calls to social service agencies or women’s
groups); one session lasting about 30 minutes
Control
Women received standard care: a wallet-size referral card listing agencies providing IPV
services (e.g. legal, social services, law enforcement). No counselling, advocacy, education,
or other services offered

Outcomes 1. SF-36 - quality of life


2. Safety Behaviours Checklist (modified)
3. Community Resource Assessment (modified)
Data for 2 outcomes (Safety Behaviours Checklist, and Community Resource Assess-
ment) were not available from the authors in a format to allow for effect sizes to be
calculated
Timing of follow-up: within 1 week of delivery (approximately between 14 to 28 weeks
postintervention session, calculated by review authors)

Notes The study recruitment dates were from 9 January to 26 July 2007
This project was funded by Puget Sound Partners for Global Health

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 57
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cripe 2010 (Continued)

Risk of bias Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Randomisation was conducted before base-
bias) line data collection “using a randomised
block design at recruitment”. No other in-
formation was available

Allocation concealment (selection bias) Unclear risk The project manager assigned participants.
No other information was available about
allocation concealment

Blinding (performance bias and detection Low risk Blinding of participants and key personnel
bias) (people providing the intervention) was not
All outcomes possible. Outcome assessors at follow-up
were different from those collecting base-
line data and providing the intervention

Incomplete outcome data (attrition bias) Low risk 6/110 (5%) missing from intervention
All outcomes group; 10/110 (9%) missing from con-
trol group. No missing women from either
group could be located at follow-up; this
was unlikely to bias the results

Selective reporting (reporting bias) Low risk All measures discussed in the ’Methods’ sec-
tion of the paper were also discussed in the
’Results’ section (although not in a format
we could utilise for two of the three out-
comes)

Baseline measurement of outcome mea- Low risk For resource use, no specific information
sures was provided, but the group frequencies ap-
pear comparable. Additional information
provided by authors on the other 2 out-
comes confirms that the groups were simi-
lar

Reliability of outcome measures Unclear risk A reliable quality of life measure was
utilised. No data were provided on the reli-
ability of the modified scales used to mea-
sure either the use of safety behaviours or
the use of community resources

Protection against contamination Unclear risk There might have been communication be-
tween women in different arms of the trial
as all recruited from one clinic

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 58
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Gillum 2009

Methods Randomisation method: papers with assignments were placed in sealed opaque en-
velopes and shuffled, women chose a sealed envelope to determine their group assign-
ment.
Analysis by intention-to-treat: no
Power calculation: yes

Participants Setting: a primary care clinic for the uninsured


Country: USA
Inclusion criteria
1. Women aged 18 + years
2. English speaking
3. Identified as abused by an intimate partner in last 12 months
Exclusion criteria
1. Women aged under 18 years
2. Could not speak English
3. Not experiencing current (last 12 months) abuse
Numbers recruited: 41 (21 intervention group, 20 control group)
Number of dropouts: 2 (2 intervention group, 0 control group)
Numbers analysed (and percentage of recruited): 39 (19 (90%) intervention group, 20
(100%) control group)
Age: mean 43 years (range 23 to 65 years)
Ethnicity: 83% African American, 15% white, 2% Latina
Socioeconomic status indicators: 39.5% unemployed, 58.5% employed, 2% disabled
Education background: 15% less than high school, 41.5% high school/General Edu-
cational Development (GED) test/trade school, 41.5% college, 2% other

Interventions Intervention
1. One-on-one personalised counselling session provided by the investigators (a
discussion around safety-promoting behaviours and women’s self-identified individual
needs); typical session lasted 30 minutes
2. Series of 6 phone calls over 3 months (at weeks 1, 2, 4, 6, 8, and 10) conducted
by a trained community health worker (consisted of goal setting, discussion of safety-
promoting behaviours, and identifying needs); duration of calls ranged from 5 minutes
to 1 hour, with an average duration of 20 minutes
Control
Women received health information brochures and a list of community resources. They
were also telephoned by the community health worker once a month, but this was only
to confirm contact information for ease of follow-up

Outcomes 1. Safety-promoting behaviour checklist


2. Community resource use
3. Partner Abuse Scale (PAS) - physical, non-physical and sexual abuse
4. Danger Assessment 2 (DA2) - risk for lethal harm
5. Chronic Pain Grade Questionnaire (adapted for study)
6. Brief Fatigue Inventory (adapted for study)
7. CES-D - depression
8. Positive screen for depression (CES-D)
9. Davidson Trauma Scale (DTS) - PTSD
Outcomes 3 to 12 measured by investigators as mediating variables only, i.e. they were not

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intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Gillum 2009 (Continued)

the focus of the reported study, and study authors provided all additional information/
data
(Stages of change also measured but not relevant to the review)

Notes Data collected 2005


No external funding

Risk of bias Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk “Papers with either intervention or con-
bias) trol group assignments were placed in pri-
vacy ’no show through’ envelopes, sealed,
and the envelopes shuffled by a nurse col-
league not associated with the study. After
informed consent, women were randomly
allocated to either the intervention group
or usual care group via their choice of a
sealed envelope with group assignment in-
side”

Allocation concealment (selection bias) Low risk “Neither the investigators nor the partic-
ipants knew which envelopes contained
which assignments”

Blinding (performance bias and detection High risk Blinding of participants and key personnel
bias) (people providing the intervention) was not
All outcomes possible. The outcome assessors also col-
lected baseline data and provided the ini-
tial face-to-face counselling session, hence
assessment was not blinded

Incomplete outcome data (attrition bias) Low risk 2/21 (10%) missing from intervention
All outcomes group, 0/20 (0%) missing from control
group. Reason given for attrition was that
the participants moved out of the catch-
ment area for eligibility at the clinic. The
dropouts were not significantly different
in demographic variables from the partici-
pants remaining in the study

Selective reporting (reporting bias) Low risk 1 of the 2 stated outcomes of interest was
not reported in the ’Results’. These data
were subsequently provided to us by the
study investigators, as were additional data
relating to the mediating variables

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intimate partner abuse (Review)
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Gillum 2009 (Continued)

Baseline measurement of outcome mea- Low risk There were no significant differences on
sures any of the outcome measures (including the
mediating variables)

Reliability of outcome measures Low risk Outcome measures were reliable

Protection against contamination High risk There was only 1 clinic serving a relatively
small population, so contact between the
women was possible. In addition, interven-
tion and control ’care’ within the clinic was
provided by the same people, and the com-
munity health worker made all interven-
tion phone calls, as well as the monthly call
to confirm contact details for controls

Hyman 2001

Methods Randomisation method: a 1:1 ratio using random numbers table


Analysis by intention-to-treat: no
Power calculation: yes, but dropout higher than expected

Participants Setting: ED of level 1 trauma centre


Country: USA
Inclusion criteria
1. Women
2. Aged 18 + years
3. Self identified as currently involved in an abusive relationship
Exclusion criteria
1. Could not speak English
2. Less than a 7th grade education
3. Unable to answer questions
4. Intoxicated
5. Already in shelter
6. Experience of trauma unrelated to their abuse within the last year
Numbers recruited: 102 (51 intervention group, 51 control group)
Number of dropouts: 49 (20 intervention group, 29 control group)
Numbers analysed (and percentage of recruited): 53 (31 (61%) intervention group, 22
(43%) control group)
Age: mean 31 years
Ethnicity: 68% non-white; 32% white
Socioeconomic status indicators (annual household income): 19% < USD 5000; 24%
USD 6000 to USD 10,000; 25% USD 11,000 to USD 20,000, 32% > USD 21,000
(values not discrete)
Education background: 11% less than high school; 39% high school diploma/General
Educational Development (GED) test; 25% some college, 25% college degree

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Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Hyman 2001 (Continued)

Interventions Intervention
Emergency Department Victim Advocacy (EDVA) programme based on empowerment
counselling (empathic support, education, safety planning, linkage with community
resources, 48 hours follow-up) to enable the woman to assess her situation, help her to
identify signs of danger, and to establish ’back-ups’ if the violence escalates; typically, the
intervention lasted 1.5 hours
Control
Women received standard Social Service care

Outcomes 1. Index of Spouse Abuse (ISA)


2. Symptoms Checklist 90 - Revised, Global Severity Index (SCL-90-R, GSI scale) -
psychological distress
3. Impact of Events Scale (IES) - post-traumatic distress
4. Perceived Stress Scale (PSS)
5. Interpersonal Self Evaluation List (ISEL) - social support
6. Semi-structured Clinical Interview for DSM-IV (SCID) - general mental health
7. Safety Behaviour Checklist
8. Use of community resources
9. Relationship status
(Other outcomes also measured but author states no data available by group randomi-
sation)
Timing of follow-up: 4 to 6 weeks (not analysed by author) and 3 to 4 months postin-
tervention

Notes Both EDVA and standard social service care already established in ED at time of evalu-
ation
19% of intervention group received control group care and 23% of control group received
the intervention

Risk of bias Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk Participants were randomised on a 1:1 ratio
bias) using a random numbers table

Allocation concealment (selection bias) Unclear risk No information was provided about who
performed the allocation or the procedure
used

Blinding (performance bias and detection Low risk Blinding of participants and key person-
bias) nel (person providing the intervention) was
All outcomes not possible. Assessors were not provided
with any information about randomisation
status at either follow-up

Incomplete outcome data (attrition bias) High risk High attrition warrants caution in inter-
All outcomes preting the study results: 20/51 (39%)
missing from intervention group; 29/51

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intimate partner abuse (Review)
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Hyman 2001 (Continued)

(57%) missing from control group. Pri-


mary reasons given for attrition were that
participants either could not be contacted
or withdrew (not reported by trial arm;
withdrawal could have been related to in-
tervention type). Initial randomisation sta-
tus did not differentiate between complet-
ing and non-completing participants

Selective reporting (reporting bias) Low risk All measures discussed in the ’Methods’
of the thesis were also discussed in the
’Results’, although not always in the form
needed by the review authors. Where still
available, such data were subsequently pro-
vided by the investigator

Baseline measurement of outcome mea- Low risk No specific information on between-group


sures differences was provided, although the
means and standard deviations seemed
comparable

Reliability of outcome measures Low risk Outcome measures with usable data were
reliable

Protection against contamination High risk 19% of women in the intervention arm of
the trial only received usual care, and 23%
of women in the control group received the
intervention

Kiely 2010

Methods Randomisation method: a computer-generated, permuted block randomisation scheme


that considered all possible risk combinations within each recruitment site
Analysis by intention-to-treat: no (authors state it was intention-to-treat as analyses
based on original allocations and not on care received, but only data for the women
completing the study were analysed)
Power calculation: yes

Participants Setting: 6 community-based prenatal care sites serving mainly minority women
Country: USA
Inclusion criteria
1. English speaking
2. Female residents of District of Columbia
3. Self-identified as minority (African American)
4. Aged ≥ 18 years
5. ≤ 28 weeks pregnant
6. Screening positive for at least one of four risk factors (IPV, depression, cigarette
smoking, environmental tobacco smoke exposure), so women did not have to be

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intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Kiely 2010 (Continued)

abused, but findings in this paper are specific to abused subset. No details on any
inclusion criteria for the clinics
Exclusion criteria: women excluded if suicidal, also ’participation exclusion’
Numbers recruited: 336 abused subset (169 intervention group, 167 control group)
Number of dropouts: 30 abused subset (19 intervention group, 11 control group)
Numbers analysed (and percentage of recruited): 306 abused subset (150 (89%) inter-
vention group, 156 (93%) control group)
Age: mean 25 years (intervention and control group)
Ethnicity: all African American
Socioeconomic status indicators: working now or before pregnancy: 74% intervention
group, 76% control group; enrolled in Medicaida : 80% intervention group, 78% control
group; WIC (Women, Infants, and Children) supplemental nutrition programme recip-
ient: 44% intervention group, 46% control group; other supplemental food programme
recipient: 99% intervention group, 97% control group; public assistance/TANF (Tem-
porary Assistance for Needy Families) recipient: 43% intervention group, 41% control
group
Education background: less than high school: 32% intervention group, 32% control
group; high school graduate/GED: 46% intervention group, 40% control group; some
college: 23% intervention group, 28% control group

Interventions Intervention
1. Multi-component intervention: 4 interventions depending on risk: advocacy for
abuse, CBT for depression, cessation/reduction therapy for smoking or passive smoking
2. The IPV intervention was based on empowerment theory and emphasised safety
behaviours: information about types of abuse and cycle of violence, a danger
assessment to assess risks and consider preventive options, development of safety plan,
and a list of community resources; delivered over 4 to 8 prenatal sessions plus 2
postpartum booster sessions, each session averaged 50 ± 15 minutes (depending on
how many of the 4 risk conditions were addressed)
Control
Women received usual prenatal care, as determined by the standard procedures at the
each prenatal care clinic

Outcomes 1. Conflict Tactics Scale (minor, severe, physical, and sexual abuse)
2. Low birth weight (< 2500 g)
3. Very low birth weight (< 1500 g)
4. Birth weight
5. Pre-term birth (37 weeks gestation)
6. Very pre-term birth (< 33 weeks gestation)
7. Gestational age at delivery
Timing of follow-up: immediately postintervention only (i.e. within 10 weeks of delivery)

Notes This study was supported by grants no. 3U18HD030445; 3U18HD030447;


5U18HD31206; 3U18HD031919; 5U18HD036104, Eunice Kennedy Shriver Na-
tional Institute of Child Health and Human Development and the National Center on
Minority Health and Health Disparities
Women were recruited in 2003, with intervention and follow-up activities continuing
to July 2004

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intimate partner abuse (Review)
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Kiely 2010 (Continued)

Risk of bias Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk “Site- and risk-specific permuted block ran-
bias) domisation to the intervention or usual care
was conducted. A computer generated ran-
domisation scheme was utilised to consider
all the possible risk combinations within
each of the recruitment sites”

Allocation concealment (selection bias) Low risk When a woman was recruited “. . . staff
would call the data coordinating centre,
where the subject’s assignment was deter-
mined.” Both the investigators and field
workers were blinded to block size

Blinding (performance bias and detection Low risk Blinding of participants and key person-
bias) nel (person providing the intervention) was
All outcomes not possible. Baseline data was collected
pre-randomisation. Follow-up data were
collected by telephone interviewers blinded
to participants’ randomisation group (as
were their supervisors)

Incomplete outcome data (attrition bias) Unclear risk 19/169 (11%) missing from intervention
All outcomes group; 11/167 (7%) missing from con-
trol group. Reasons given for attrition not
stated, although completers randomised to
the intervention did not differ significantly
from completers in the control group

Selective reporting (reporting bias) Low risk All measures discussed in the ’Methods’ sec-
tion of the paper were also discussed in the
’Results’ section

Baseline measurement of outcome mea- Low risk The investigators stated that the groups did
sures not differ on any of the abuse subscales
(pregnancy outcomes not relevant at base-
line)

Reliability of outcome measures Low risk Outcome measures were reliable

Protection against contamination Unclear risk There might have been communication be-
tween women in different arms of the trial,
as individual clinics recruited women allo-
cated to intervention and control groups

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intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
McFarlane 2000

Methods Randomisation method: random determination of the specific intervention into which
each clinic would enter women in the first month of the trial, with each clinic rotating
through a specified sequence of three interventions, entering all participants for a given
month into the same intervention
Analysis by intention-to-treat: no
Power calculation: yes

Participants Setting: 2 antenatal clinics


Country: USA
Inclusion criteria: women physically or sexually abused by current or former male
partner in year prior to or during pregnancy
Exclusion criteria: none stated
Numbers recruited: 329 (118 ’outreach’, 98 ’counselling’, 113 ’brief ’)
Number of dropouts: 70 (26 ’outreach’, 25 ’counselling’, 19 ’brief ’)
Numbers analysed (and percentage of recruited): 259 (92 (78%) ’outreach’, 73 (74%)
’counselling’, 94 (83%) ’brief ’)
Age: mean 24 years (range 15 to 42 years)
Ethnicity: all Latina
Socioeconomic status indicators: 23% employed; 53% financially supported them-
selves; annual household income: 66% < USD 10,000; 6% > USD 20,000
Education background: mean 8.4 (SD 3.2) years of education

Interventions 3 intervention groups


1. ’Counselling’ - unlimited access during clinic opening times to onsite bilingual
DV advocate offering support, education, referral, assistance in accessing resources;
available by appointment or drop-in for the duration of pregnancy
2. ’Outreach’ - as ’counselling’, plus the services of a bilingual trained, non-
professional mentor mother offering support, education, referral, assistance in
accessing resources; achieved through personal visits and telephone contact
3. ’Brief ’ - women offered wallet-sized card with information on community
resources and a brochure
(The ’outreach’ and ’counselling’ interventions are equivalent to other forms of inter-
vention reported in this review)
(The ’brief ’ intervention is equivalent to the control group care provided in other trials
reported in this review)

Outcomes 1. Severity of Violence Against Women Scale (SVAWS) - threats and actual physical
abuse
2. Community Resource Assessment
Timing of follow-up: 2, 6, 12, 18 months postintervention (also at 24 months, but no
analyses)

Notes This research was supported in part by the U.S. Centers for Disease Control and Pre-
vention, National Center for Injury Prevention and Control, and by the Houston De-
partment of Health and Human Services (HDHHS)

Risk of bias Risk of bias

Bias Authors’ judgement Support for judgement

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intimate partner abuse (Review)
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McFarlane 2000 (Continued)

Random sequence generation (selection Unclear risk “. . . [I]nitiated by randomly determining


bias) the specific intervention into which each
clinic would enter during the first month
of the study . . . each clinic then rotated
through a specified sequence of the three
interventions, entering all participants for
a given month into the same intervention.
” Additionally, the investigators state “the
procedure . . . did not involve individu-
ally randomising women using a technique
such as a random numbers table or com-
puter generated random numbers.” No in-
formation on the technique actually used
was provided

Allocation concealment (selection bias) High risk Key personnel may have foreseen the as-
signments

Blinding (performance bias and detection Unclear risk Blinding of participants and key person-
bias) nel (person providing the intervention) was
All outcomes not possible. No information was provided
in relation to the blinding of the outcome
assessor(s)

Incomplete outcome data (attrition bias) Unclear risk 26/118 (22%) missing from ’outreach’ in-
All outcomes tervention group, 25/98 (26%) missing
from ’counselling’ intervention group, 19/
113 (17%) missing from ’brief ’ control
group. Reasons given for attrition were not
discussed but two analyses conducted to es-
timate any effects due to loss of follow-up
showed no significant differences among
the groups

Selective reporting (reporting bias) Low risk Both measures discussed in the ’Methods’
section of the paper were also discussed in
the ’Results’ section

Baseline measurement of outcome mea- Low risk The investigators stated that the groups did
sures not differ on any of the outcome variables

Reliability of outcome measures Low risk The primary outcome (physical and emo-
tional abuse) was reliable. No data were
provided on the reliability of the scale used
to measure the use of community resources.
The investigators stated that recall bias may
have resulted from an interruption in fund-
ing that delayed the completion of some of

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intimate partner abuse (Review)
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McFarlane 2000 (Continued)

the follow-up interviews, but this was not


related to trial arm

Protection against contamination Unclear risk Not addressed explicitly, although the
study design may have minimised poten-
tial contamination as women in the differ-
ent arms of the trial were unlikely to meet,
and the treatments were not provided by
the same people

McFarlane 2006

Methods Randomisation method: allocated by week of recruitment


Analysis by intention-to-treat: no
Power calculation: yes

Participants Setting: recruited in 2 primary care public health clinics and 2 Women, Infants, and
Children clinics (WICs)
Country: USA
Inclusion criteria
1. Women
2. Aged 18 to 44 years
3. English or Spanish speaking
4. Identified by nurse as physically or sexually abused by an intimate partner within
last 12 months
Exclusion criteria: none stated
Numbers recruited: 360 (180 intervention group, 180 control group)
Number of dropouts: 41 (19 intervention group, 22 control group)
Numbers analysed (and percentage of recruited): 319 (161 (89%) intervention group,
158 (88%) control group)
Age: mean 30 years intervention group, mean 31 years control group
Ethnicity: 12% white, 28% black, 60% Latina, 1% other
Socioeconomic status indicators (annual household income): 32%, < USD 5000; 21%,
USD 5000 to USD 10,000; 31%, USD 10,000 to USD 20,000; 17%, > USD 20,000
Education background: 49% less than high school diploma; 29% high school graduate;
22% > high school

Interventions Intervention
Nurse case management empowering abused women by increasing independence/con-
trol: focus on protection/safety, enhanced choice-making/problem solving; nurse facili-
tates this by giving anticipatory guidance and guided referrals tailored to woman’s indi-
vidual needs; sessions lasted for 20 minutes, on average, and were provided at baseline
and at 6-month intervals for 2 years
Control
Provision of a referral card listing a safety plan and sources for IPV services; no counselling,
education, referrals or other services were offered

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intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
McFarlane 2006 (Continued)

Outcomes 1. Severity of Violence Against Women Scale (SVAWS) - threats and actual physical
abuse
2. Danger Assessment Scale (DAS) - homicide risk
3. Employment Harassment Scale (EHS) - harassment at work
4. Community Resource Assessment
5. Safety Behaviour Checklist
Timing of follow-up: 6, 12, 18 and 24 months, beginning in August 2001 and ending
in August 2004

Notes This research was supported by a grant from the Agency for Healthcare Research and
Quality RO1HS11079
Participant recruitment began in February 2001 and ended in June 2002

Risk of bias Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk “ . . . [E]ach week of the study was ran-
bias) domised by a computer-generated process
so that each woman consenting would be
assigned to an intervention group based
on the week in which she was assessed for
abuse”

Allocation concealment (selection bias) High risk The randomisation was completed by the
project manager and presented to the re-
search nurses responsible for recruitment at
the beginning of each week

Blinding (performance bias and detection High risk Blinding of participants and key personnel
bias) (people providing the intervention) was not
All outcomes possible. The outcome assessors also pro-
vided the intervention, hence assessment
was not blinded

Incomplete outcome data (attrition bias) Low risk 19/180 (11%) missing from intervention
All outcomes group, 22/180 (12%) missing from control
group. Reason given for attrition was that
the participants could not be contacted.
There was no difference in trial arm

Selective reporting (reporting bias) Low risk All measures discussed in the ’Methods’ sec-
tion of the paper were also discussed in the
’Results’ section

Baseline measurement of outcome mea- Low risk No specific information on between-group


sures differences was provided, although the
means and standard deviations seemed
comparable

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intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
McFarlane 2006 (Continued)

Reliability of outcome measures Low risk Four of the outcomes (including the pri-
mary outcomes of abuse) were reliable. No
data were provided on the reliability of the
scale used to measure the use of commu-
nity resources

Protection against contamination High risk The same healthcare professionals man-
aged both women in the intervention and
the control arms of the trial

Sullivan 1991

Methods Randomisation method: random allocation with ratio of 2:1 (intervention: control),
no stratification
Analysis by intention to treat: no
Power calculation: no

Participants Setting: community (recruited in shelter)


Country: USA
Inclusion criteria: abused women living in a refuge and intending to leave their abusers
Exclusion criteria: women who left the refuge quickly without completing exit form
or telling anyone where they were going, returned immediately to abusers, left the area,
spoke no English
Numbers recruited: 46 (30 intervention group, 16 control group)
Number of dropouts: 5 (5 intervention group, 0 control group)
Numbers analysed (and percentage of recruited): 41 (25 (83%) intervention group, 16
(100%) control group)
Age: mean 28 years (range 19 to 39 years)
Ethnicity: 56% white, 39% African American, 5% Latina
Socioeconomic status indicators: 63% unemployed, 71% receiving some government
aid
Education background: 59% educated to high school level or less

Interventions Intervention
Intensive one-on-one services with a trained paraprofessional advocate who assisted
women in accessing needed community resources within 1 week of leaving the shelter;
10 weeks of advocacy, usually meeting twice a week: 4 to 6 hours in person and another
2 hours telephone contact
Control
Women received standard shelter care and no additional post-shelter service

Outcomes 1. Conflicts Tactics Scale (CTS), Violence subscale (modified) - experience/extent of


abuse
2. Effectiveness in Obtaining Resources (EOR) scale
3. Independence from abuser (1 question about current relationship)
Timing of follow-up: mid-intervention, immediate postintervention, 10 weeks postin-
tervention

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Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Sullivan 1991 (Continued)

Notes Partially funded by the George Gund Foundation and the Michigan Department of
Mental Health
Data were collected between 1986 and 1988

Risk of bias Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk “ . . . [W]omen were randomly assigned
bias) to either of the two conditions, stratify-
ing for order. Two-thirds were randomly as-
signed to the [intervention], and one-third
to the control condition.” No further in-
formation was provided

Allocation concealment (selection bias) Unclear risk No information was provided about who
performed the allocation or the procedure
used

Blinding (performance bias and detection High risk Blinding of participants and key personnel
bias) (people providing the intervention) was not
All outcomes possible. Also, the outcome assessors were
not blinded as at data collection they had
to ask intervention group participants what
they thought about the advocacy process

Incomplete outcome data (attrition bias) High risk Attrition differs markedly by group: 5/30
All outcomes (17%) missing from intervention group, 0/
16 (0%) missing from control group. Rea-
son given for attrition was that 5 partici-
pants were no longer ’eligible’, as they had
to receive at least 3 weeks of services and
had dropped out (3 of these because they
had returned to their abusers). This may af-
fect outcome effect size. However we note
that the poor attrition is a function of the
study design, where women had to attend
at least 3 advocacy sessions to be eligible,
which could not apply to the controls

Selective reporting (reporting bias) Low risk All measures discussed in the ’Methods’ sec-
tion of the paper were also discussed in the
’Results’ section

Baseline measurement of outcome mea- Low risk The investigators stated that the groups did
sures not differ on severity of abuse; effectiveness
in accessing resources was not measured at
baseline

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intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Sullivan 1991 (Continued)

Reliability of outcome measures Low risk Outcome measures were reliable

Protection against contamination Unclear risk There might have been communication be-
tween women in different arms of the trial,
as all were recruited from the same shelter

Sullivan 1992

Methods Randomisation method: only states ’sealed envelopes’


Analysis by intention-to-treat: no
Power calculation: no

Participants Setting: community (recruited in shelter)


Country: USA
Inclusion criteria: abused women who stayed at least 1 night in shelter and intended
to stay in area for at least 3 months postshelter
Exclusion criteria: none stated
All data below based on original sample of women (see notes)
Numbers recruited: 146 (76 intervention group, 70 control group)
Number of dropouts: 22 (14 intervention group, 8 control group)
Numbers analysed (and percentage of recruited): 124 (62 (82%) intervention group,
62 (89%) control group)
Age: mean 28 years (range 17 to 61 years)
Ethnicity: 42% African American, 46% white, 7% Latina, 2% Asian American, 3%
other
Socioeconomic status indicators: 61% unemployed, 81% receive government aid
Education background: 64% educated to high school level, 34% some college education

Interventions Intervention group


Intensive one-on-one services with an advocate who assisted women to devise a safety
plan and access community resources; 10 weeks of advocacy, usually meeting twice a
week: mean 7 hours contact per week for 10 weeks after leaving shelter
Control group
Women received standard shelter services provided to all residents, and then usual after-
shelter care (if any)

Outcomes 1. Conflicts Tactics Scale (CTS), violence subscale (modified)


2. Index of Psychological Abuse (IPA)
3. Quality of life (adapted from measure by Andrews 1976)
4. The Adult’s Social Support Questionnaire
5. Centre for Epidemiological Studies - Depression scale (CES-D)
6. Rape Aftermath Symptom Test (RAST) - long-term fear and anxiety
7. Effectiveness in obtaining resources (EOR) (author’s own scale), later changed to
difficulties in obtaining resources (DOR)
8. Independence from abuser (one question about current relationship)
9. Self efficacy (authors’ own scale)
10. Emotional attachment to abuser (author’s own scale)
Timing of measurement: followed up immediate postintervention, and at 6, 12, 18,

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Sullivan 1992 (Continued)

24, and 36 months postintervention. Most effect sizes calculated for follow-up at ≤ 12
months and 12 to 24 months are based on the larger sample size. (N.B. outcomes 2 and
5 not followed up beyond 2 years)
(Locus of control was measured at baseline and at 6 months follow-up, but then dropped;
no data were available)

Notes 1992, 1994 and 2005 papers report on original sample recruited; but more women joined
over time, and 1999 paper reports on a larger sample (the paper states 284, but personal
communication with the investigators verifies this to be 283); participants’ characteristics
were similar to those of original sample
Funded by the U.S. National Institute of Mental Health. Data were collected between
1990 and 1997

Risk of bias Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk “Group selection was random, stratifying
bias) for order and for whether or not a woman
was romantically involved with her as-
sailant.” No further information was pro-
vided

Allocation concealment (selection bias) Low risk “The interviewer opened a sealed envelope
which indicated whether the woman would
receive the services of an advocate. The in-
terviewer did not know to which group a
woman would be assigned until after the
interview was completed . . .”

Blinding (performance bias and detection Unclear risk Blinding of participants and key person-
bias) nel (people providing the intervention) was
All outcomes not possible. The outcome assessors were
not the same people providing the inter-
vention, and they were separately trained,
but no other information was provided

Incomplete outcome data (attrition bias) High risk 14/76 (18%) missing from intervention
All outcomes group, 8/70 (11%) missing from control
group in the original sample. Reasons given
for attrition: 5 participants in the interven-
tion arm were no longer ’eligible’ as they
had to receive at least 3 weeks of services (4
dropped out and returned to their abusers
and 1 woman was murdered. This may af-
fect outcome effect size); the remainder (in
either group) could not be located. We note
that intervention attrition is a function of
the study design, where women had to at-

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Sullivan 1992 (Continued)

tend at least 3 advocacy sessions to be eligi-


ble, which could not apply to the controls

Selective reporting (reporting bias) Low risk All measures discussed in the ’Methods’ sec-
tion of the paper were also discussed in
the ’Results’ section, although not always
in the form needed by the review authors.
Where still available, the investigators pro-
vided such data

Baseline measurement of outcome mea- Low risk Baseline measures taken. No further infor-
sures mation provided for the original sample,
but for the larger sample the investigators
stated there were no statistical differences
for the 5 main outcome variables

Reliability of outcome measures Low risk Outcome measures were reliable

Protection against contamination Unclear risk It is possible that there might have been
communication between women in differ-
ent arms of the trial, as all were recruited
from the same shelter

Sullivan 2002

Methods Randomisation method: none stated


Analysis by intention-to-treat: no
Power calculation: none stated

Participants Setting: community - working in the family’s home (recruited primarily in shelter)
Country: USA
Inclusion criteria
1. Physical violence from an intimate partner or ex-partner in previous 4 months
2. Intended to stay in area for 8 months
3. At least 1 child between 7 to 11 years living with them
4. At least 1 of these required to participate
Exclusion criteria: none stated
Numbers recruited: 80 (45 intervention group, 35 control group)
Number of dropouts: 4 (trial arm not stated)
Numbers analysed (and percentage of recruited): 78 (98%) as some data imputed (45
(56%) intervention group, 33 (41%) control group)
Age: mean 31 years
Ethnicity: 49% white, 39% African American, 5% Latina, 5% multiracial, 1% Asian,
1% Native American
Socioeconomic status indicators: mean income USD 1200 per month, 88% receiving
government aid, 44% employed
Education background: none stated

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intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Sullivan 2002 (Continued)

Interventions Intervention
Multi-component advocacy intervention to improve the well-being of mothers and self-
confidence of their children, and to protect against continued violence; 3 components:
1. Advocacy for abused mothers, to help mothers generate, mobilise, and access
community resources
2. Advocacy for children (similar to above)
3. Support and education group for the children: children attended a 10-week
support and education group; intervention based on individual needs of mother and
child, full programme lasted 16 weeks, families saw advocates for a median 8 hours/
week, averaging 5 hours with children and an additional 3 hours with the women
Control
Women had usual access to services available to community residents

Outcomes 1. Overall abuse - composite of (a) shortened Index of Psychological Abuse (IPA),
(b) Conflict Tactics Scale (CTS) modified Physical Violence subscale
2. Centre for Epidemiological Studies - Depression scale (CES-D)
3. Rosenberg Self Esteem Inventory (RSEI)
4. Quality of life (adapted from measure by Andrews 1976)
5. The Adult’s Social Support Questionnaire
Timing of follow-up: immediate and 4 months postintervention
(Child-related measures not included in this review)

Notes Breakdown of numbers recruited: personal communication (Sullivan 2002)


Funded by the U.S. National Institute of Mental Health. Data were collected 1990 to
1997

Risk of bias Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk “. . . [W]omen were randomly assigned
bias) to either the experimental or the control
condition.” No other information was pro-
vided

Allocation concealment (selection bias) Unclear risk No information was provided

Blinding (performance bias and detection Unclear risk Blinding of participants and key personnel
bias) (people providing the intervention) was not
All outcomes possible. No information was provided in
relation to the outcome assessors

Incomplete outcome data (attrition bias) Low risk 4 participants dropped out, not stated by
All outcomes trial arm. However, where possible, miss-
ing data were imputed resulting in 0/45
(0%) ’missing’ from intervention group, 2/
35 (6%) ’missing’ from control group. Rea-
sons given for attrition were that 2 women
declined further involvement and 2 could

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intimate partner abuse (Review)
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Sullivan 2002 (Continued)

not be located (not reported by trial arm)

Selective reporting (reporting bias) Low risk All measures discussed in the ’Methods’ sec-
tion of the paper were also discussed in
the ’Results’ section, although not always
in the form needed by the review authors.
Study investigator subsequently provided
such data

Baseline measurement of outcome mea- Low risk The investigators stated that the groups did
sures not differ on any of the outcome variables

Reliability of outcome measures Low risk Outcome measures were reliable

Protection against contamination Unclear risk It is possible that there might have been
communication between women in differ-
ent arms of the trial

Taft 2011

Methods Randomisation method: cluster-randomised - not stated explicitly how clusters were
generated, but allocations were concealed in opaque envelopes and randomly selected by
a person outside the study; GP clinics were randomised by number of GPs participating
(1 or 2), Maternal and Child Health (MCH) clinics were randomised by team (stratified
by numbers of births per local government area)
Analysis by intention-to-treat: no (authors state it was ITT analyses based on original
allocations and not on care received, but only data for the women completing the study
were analysed)
Power calculation: yes, but the required number of 350 women in each trial arm not
attained

Participants Setting: recruited in primary care clinics - general practices offering shared care (care for
pregnant patients shared between local GP and maternity hospital) and MCH clinics
Country: Australia
Inclusion criteria: women aged 16 + years attending clinics, pregnant or with at least one
child ≤ 5 years, disclosed intimate partner violence or were psychosocially distressed (and
symptoms suggested intimate partner violence); authors were contacted and provided
data for moderately to severely abuse women only. (Clinic inclusion criteria: GP clinics
offering shared care and MCH clinics)
Exclusion criteria: women with serious mental illnesses and not taking medication,
inadequate English or Vietmanese for informed consent
Numbers recruited: 141 abused subset (93 intervention group, 48 control group)
Numbers dropouts: 38 abused subset (22 intervention group, 16 control group)
Numbers analysed (and percentage of recruited): 103 abused subset (71 (76%) inter-
vention group; 32 (67%) control group)
Indicators below are for total sample of n = 141
Age: mean 32 years
Ethnicity: born overseas: 36% intervention group, 32% control group
Socioeconomic status indicators: income from welfare/pension: 62% intervention

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intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Taft 2011 (Continued)

group, 53% control group; healthcare (subsidy) card: 74% intervention group, 70%
control group
Education background (year 12 or less): 47% intervention group, 51% control group

Interventions Intervention
MOSAIC model: combined social support, advocacy, and antenatal mentoring: non-
judgemental listening/support/friendship; maintaining contact/support (weekly on av-
erage) through phone calls, home visiting/outings; assistance in developing safety strate-
gies appropriate to women’s circumstances; developing a trusting relationship/modelling
a sense of hope; providing parenting information/support; providing information/as-
sisting referral to community services/resources (especially family violence services) for
women and children; intervention delivered by trained and supported non-professional
mentor mothers for up to 12 months
Control
Women in the control group received an information sheet for mothers; this included
family violence service contact details

Outcomes Followed up immediate postintervention only


1. Composite Abuse Scale (CAS)
2. Edinburgh Postnatal Depression Scale (EPDS)
3. Short-form 36 (SF-36) - well-being (quality of life)
4. Medical Outcomes Scale Short Form (MOS-SF) - social support

Notes Multi-component intervention: advocacy and parenting support for abused mothers
Child-related measures not included in this review
Development and piloting of the MOSAIC intervention model and the design of the
trial occurred over a period of 3 years (2001 to 2003)
Research funding: National Health and Medical Research Council, Victorian Health
Promotion Foundation (VicHealth)
Implementation funding: Victorian Government Community Support Grants Fund,
beyondblue - the depression initiative. Angela Taft, one of the authors of this review,
is supported by a Victorian Health Promotion Foundation (VicHealth) Public Health
Fellowship. Lisa Gold is supported by NHMRC Population Health Capacity Building
Grant 425855

Risk of bias Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection High risk Cluster-randomised: randomisation oc-


bias) curred at 2 public meetings to which GPs/
MCH team leaders were invited “to ensure
the fairness of the process and to check the
contents of the envelopes prior to being
sealed” - but no details about the randomi-
sation procedure used. A large percentage
of clinics in both arms did not refer any
potential participants

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Taft 2011 (Continued)

Allocation concealment (selection bias) High risk Clinic allocations (as cluster-randomised)
“were concealed in opaque envelopes and
randomly selected by someone outside the
study”. However, staff recruiting individual
participants were aware of allocation status,
and authors report selection bias because of
poor participation by control clinics

Blinding (performance bias and detection High risk Blinding of participants and key personnel
bias) (people providing the intervention) was not
All outcomes possible. Research staff were not blinded as
they “fully briefed participants in the in-
tervention arm about the mentoring pro-
gramme, negotiated informed consent and
collected follow-up data about mentoring
from participants in the intervention arm”

Incomplete outcome data (attrition bias) High risk Large attrition: 43/106 clinics did not re-
All outcomes fer any potential participants (35% in-
tervention versus 42% control). Of those
women recruited, 22/93 (24%) missing
from abused subset of intervention group,
16/48 (33%) missing from abused subset
of control group. Reasons for attrition not
stated. No test for differences across groups

Selective reporting (reporting bias) Low risk All measures discussed in the ’Methods’ sec-
tion of the paper also discussed in the ’Re-
sults’ section

Baseline measurement of outcome mea- Low risk No statistics given, but additional infor-
sures mation provided by authors for the abused
subset indicates the groups were similar
in terms of severity of abuse, depression
and well-being, although the intervention
group did report slightly less social support

Reliability of outcome measures Low risk Outcome measures were reliable

Protection against contamination Low risk Allocation by clinic, so little chance for staff
or women to communicate with each other

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intimate partner abuse (Review)
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Tiwari 2005

Methods Randomisation method: generated by computer and concealed in consecutively num-


bered sealed envelopes by a researcher not involved in the study
Analysis by intention-to-treat: yes
Power calculation: yes

Participants Setting: public hospital antenatal clinic


Country: China (Hong Kong)
Inclusion criteria
1. Pregnant women
2. Aged 18 + years
3. < 30 weeks gestation
4. Attending first antenatal appointment
5. Identified as abused by an intimate partner within last 12 months
Exclusion criteria: abuser was not a male partner
Numbers recruited: 110 (55 intervention group, 55 control group)
Number of dropouts: 4 (4 intervention group, 0 control group)
Numbers analysed (and percentage of recruited): 106 (51 (93%) intervention group,
55 (100%) control group)
Age: mean 30 years intervention group, mean 31 years control group
Ethnicity: all Chinese
Socioeconomic status indicators: intervention group: 13% < HKD 10000; 28% HKD
10,000 to HKD 20,000; 55.5% > HKD 20,000; control group: 18.6% < HKD 10,000;
39% HKD 10,000 to HKD 20,000; 36.6% > HKD 20,000 (as reported in the paper)
Education background: none stated

Interventions Intervention
Intervention based on empowerment to enhance abused women’s independence and
control; consisted of advice in the areas of safety, decision making and problem solving;
helped women to positively value themselves; intervention delivered by a senior researcher
(a midwife with a degree in counselling) and lasted about 30 minutes, an information
brochure also provided
Control
Women received standard care: a wallet-sized card with information on community
resources for abused women, which included shelter hotlines, law enforcement, social
services and non-government organisations

Outcomes 1. Conflicts Tactics Scale (CTS) modified and translated version of Form-R (3
subscales - physical violence, verbal aggression, reasoning) and one extra item on sexual
abuse
2. SF-36 - quality of life (Chinese version)
3. Edinburgh Postnatal Depression Scale (EPDS) (Chinese version)
Timing of follow-up: 6 weeks post delivery (so, depending on gestation age at recruit-
ment, about 16 to 34 weeks postintervention)

Notes Average national income: HKD 11,000


This study was supported by a Low Budget High Impact Research Grant awarded by
the University of Hong Kong
The study was undertaken between May 2002 and July 2003

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intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Tiwari 2005 (Continued)

Risk of bias Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk The allocation schedule was computer-
bias) generated

Allocation concealment (selection bias) Low risk Allocation was concealed by the use of con-
secutively numbered sealed envelopes, a re-
searcher not involved in the study carried
out this task

Blinding (performance bias and detection Low risk Blinding of participants and key personnel
bias) (people providing the intervention) was not
All outcomes possible. Outcome assessors were blinded
to study design/hypotheses and group al-
location, and this appeared to be success-
ful (questions on satisfaction with care not
asked until all outcome data collected, no
participant revealed their randomisation
status early). Data analysed by people not
involved in the design of the trial

Incomplete outcome data (attrition bias) Low risk 4/55 (7%) missing from intervention
All outcomes group, 0/55 missing from control group
(0%). Reason given for attrition was that
the participants could not be traced

Selective reporting (reporting bias) Low risk All measures discussed in the ’Methods’ sec-
tion of the paper were also discussed in the
’Results’ section

Baseline measurement of outcome mea- Low risk No specific information on between-group


sures differences was provided, although the
means and standard deviations seemed
comparable. (Study investigators calculated
mean change from baseline scores)

Reliability of outcome measures Low risk Outcome measures were reliable

Protection against contamination Low risk Only 1 clinic, but study investigators took
active steps to minimise bias: person ad-
ministering the intervention was separated
from all control group participants, clinic
waiting times minimised to reduce the
chance of the 2 groups meeting, allocation
status not recorded in the medical record

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intimate partner abuse (Review)
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Tiwari 2010

Methods Randomisation method: generated by computer and concealed in serially numbered


opaque envelopes by a researcher not involved in participant recruitment
Analysis by intention-to-treat: yes
Power calculation: yes

Participants Setting: community centre providing a range of social, health, child care, educational,
and recreational services for users of all age groups
Country: China (Hong Kong)
Inclusion criteria
1. Community-dwelling Chinese women
2. Aged 18 + years
3. Residing or working in one of the districts covered by the community centre
4. Screening positive for partner violence by an intimate partner within last 12
months
Exclusion criteria: women not communicating in Cantonese or Putonghua (the 2 main
dialects in Hong Kong)
Numbers recruited: 200 (100 intervention group, 100 control group)
Number of dropouts: none
Numbers analysed (and percentage of recruited): 200 (100 (100%) intervention group,
100 (100%) control group)
Age: mean 38 years intervention group, 38 years control group
Ethnicity: all Chinese (born in Hong Kong: 33% intervention group, 43% control
group; born in mainland China: 65% intervention group, 56% control group)
Socioeconomic status indicators: employed: 30% intervention group, 32% control
group; experiencing financial hardship: 72% intervention group, 73% control group;
in need of financial support: 65% intervention group, 58% control group; receiving
comprehensive social security assistance: 33% intervention group, 9% control group
Education background: ≤ 6th grade: 25% intervention group, 30% control group; 7th
to 13th grade: 71% intervention group, 65% control group; postsecondary education:
4% intervention group, 5% control group

Interventions Intervention (2 components)


1. Empowerment: included information about the cycle of violence, protection and
safety, options and resources available, choice making and problem solving; this was a
one-off face-to-face session delivered by a social worker and lasted about 30 minutes
(range 20 to 45 minutes).
2. Telephone social support: included non-judgemental listening, discussion of
needs, offering information or referral to other professionals/services as required;
consisted of 12 scheduled weekly telephone calls lasting about 10 to 20 minutes each
call, and 24-hour access to a hotline for additional social support. In addition, women
could receive the usual care services offered by the centre or its outreach sites.
Control
Women in the control group received the usual community services provided by the
centre or its outreach sites; women could decide on the uptake of services according to
their own needs (child care, healthcare and promotion, recreational facilities); at the time
of the study, there was no provision of standard care for abused women in the community
except crisis intervention for those severely abused

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intimate partner abuse (Review)
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Tiwari 2010 (Continued)

Outcomes 1. Chinese version of the Revised Conflicts Tactics Scale (C-CTS2) modified and
translated version (3 subscales - Physical Assault, Psychological Aggression, Sexual
Coercion)
2. Chinese version of the Beck Depression Inventory II (C-BDI-II)
3. Short-form Health Survey 12 (SF-12) - quality of life
4. Chinese and culturally adapted version of McFarlane’s Safety-Promoting
Behaviour Checklist
(Outcome 5 reported in subsequent 2012 paper)
Timing of follow-up: 6 months postintervention (i.e. 6 months after cessation of the 12
weeks of telephone support)

Notes This study was supported by the Health and Health Services Research Fund awarded by
the Food and Health Bureau of the Hong Kong SAR Government (Project # 04060741)
Study Start Date: February 2007, Study Completion Date:June 2009, Primary Comple-
tion Date: December 2008 (Final data collection date for primary outcome measure)

Risk of bias Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk Participants randomised (1:1) to groups
bias) “according to a list of random permutations
prepared by computer-generated blocked
randomisation performed by a research
staff member who had not been involved
in participant recruitment”

Allocation concealment (selection bias) Low risk “The block size was kept secure by the ran-
domiser, and the order of allocation was
centrally controlled to avoid any bias in se-
lection. The allocation sequence was con-
cealed in opaque envelopes. At the time
of randomisation, the research assistant
who had successfully recruited a partici-
pant called the site investigator, who then
opened the envelope containing the group
assignment. To ensure random assignment
. . . no detail was provided to the site in-
vestigator about the identity of the partici-
pant”

Blinding (performance bias and detection Low risk Blinding of participants and key personnel
bias) (people providing the intervention) was not
All outcomes possible. Assessors were blinded; they “were
not involved in the design of the study, did
not know the study hypotheses, and were
blinded to group assignment” . . . this ap-
peared to be sustained “because none of

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Tiwari 2010 (Continued)

the assessors knew the group assignment


of the participants until they came to the
last question, which solicited the partic-
ipants’ evaluation of the intervention or
usual community services”

Incomplete outcome data (attrition bias) Low risk There were no missing data
All outcomes

Selective reporting (reporting bias) Low risk All measures discussed in the ’Methods’ sec-
tions of the papers also discussed in the ’Re-
sults’ sections

Baseline measurement of outcome mea- Low risk There were no significant differences on
sures any of the outcome measures

Reliability of outcome measures Low risk Outcome measures were reliable

Protection against contamination Unclear risk Participation was solicited through several
means but primarily through centre events/
publicity, so there were some opportunities
for women in the two arms to meet - even
though the centre served a large population
(approximately 800,000)

DV: domestic violence; ED: emergency department; GP: general practitioner; IPV: intimate partner violence; ITT: intention-to-treat;
MOSAIC: MOther’sS Adovcates In the Community; PTSD: post-traumatic stress disorder; SF-36: 36-item Short Form Health
Survey.
a Medicaid: social healthcare programme for low-income households in the USA.

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Anderson 2012 Not a randomised controlled trial (observational study)

Andersson 2013 Data not available for the subset of women who had experienced abuse

Andrews 2011 Not a randomised controlled trial (before-and-after study, women acted as own controls)

Bacchus 2007 Not a randomised controlled trial (before-and-after study, women acted as own controls)

Becker 2008 Not a randomised controlled trial (before-and-after study, parents acted as own controls)

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intimate partner abuse (Review)
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(Continued)

Bell 2001 Not a randomised controlled trial (before-and-after study, matched parallel groups)

Bloom 2014 Not advocacy according to our definition

Carlson 2012 Not advocacy according to our definition. No separate data for the minority of women experiencing IPV

Casey 2007 Not a randomised controlled trial (before-and-after study with historical controls)

Champion 2007 Not advocacy according to our definition. Secondary analysis of data from a randomised controlled trial
comparing outcomes for abused women with non-abused women

Coker 2012 Not a fully cluster-randomised controlled trial (3 out of 8 clinics not randomised)

Cupples 2011 Not a group of abused women

Curry 2006 A randomised controlled trial, but no separate data for the subset of abused women

Davidson 2012 Not a randomised controlled trial (before-and-after study, women acted as own controls)

DePrince 2012 A randomised controlled trial, but compared two forms of advocacy (no control group)

Dichter 2012 Not a randomised controlled trial (observational study)

Eden 2015 Not advocacy according to our definition

El-Mohandes 2008 A randomised controlled trial, but no separate data for the subset of abused women

El-Mohandes 2011 A randomised controlled trial, but no separate data for the subset of abused women

Feder 2011 Not a test of advocacy

Ford-Gilboe 2011 Not a randomised controlled trial (before-and-after study, matched parallel groups)

Graham-Bermann 2013 Not advocacy according to our definition

Grip 2011 Not a randomised controlled trial (observational study)

Harris 2002 Not a randomised controlled trial (observational study)

Hirani 2010 Not advocacy according to our definition

Houry 2011 Not advocacy according to our definition

Humphreys 2011 Not advocacy according to our definition; outcomes not relevant to review

Jack 2012 Not an randomised controlled trial (development of an intervention with no planned evaluation)

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intimate partner abuse (Review)
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(Continued)

James 2014 Not advocacy according to our definition

Johnson 2011 Not advocacy according to our definition. The HOPE programme is fundamentally a psychological (CBT)
intervention and does not have a substantial advocacy component. The linking to resources consistent
with our definition of advocacy is not specific to the intervention arm participants

Jouriles 2001 The ’usual care’ control group received some advocacy

Jouriles 2009 The ’usual care’ control group received some advocacy

Kelly 1999 Not a randomised controlled trial (before-and-after study with historical controls)

Kendall 2009 Not a randomised controlled trial (observational study)

Koziol-McLain 2015 Not advocacy according to our definition

Kramer 2012 Not a randomised controlled trial (before-and-after study, women acted as own controls)

Krasnoff 2002 Not a randomised controlled trial (observational study)

Krishnan 2012 Not a randomised controlled trial (qualitative evaluation of an intervention)

Kyegombe 2014 Not advocacy according to our definition

Lindsay 2013 Not advocacy according to our definition

McFarlane 1997 Not a randomised controlled trial (before-and-after study, women acted as own controls)

McFarlane 2002 The ’usual care’ control group received some advocacy

McKean 2004 Not a randomised controlled trial (matched parallel groups)

McLelland 2008 Not a randomised controlled trial (observational study)

Miller 2011 Not advocacy according to our definition

Miller 2014 Not advocacy according to our definition

Morrissey 2005 Not a randomised controlled trial (unmatched parallel groups)

Muelleman 1999 Not a randomised controlled trial (before-and-after study with historical controls)

Orchowski 2012 Not a randomised controlled trial (observational study). Not a group of abused women

Parker 1999 Not a randomised controlled trial (matched parallel groups)

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intimate partner abuse (Review)
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(Continued)

Peled 2010 Not a randomised controlled trial (before-and-after study, women acted as own controls). Not advocacy
according to our definition

Reilly 2004 Not a randomised controlled trial (before-and-after study with historical controls). No separate data for
the subset of abused women. Outcomes not relevant to review

Robinson-Whelen 2014 Data not available for the subset of women who had experienced abuse

Saftlas 2014 Not advocacy according to our definition

Saggurti 2014 Data not available for the subset of women who had experienced abuse

Simmons 2011 Not a randomised controlled trial (observational study)

Song 2010 Not a randomised controlled trial (before-and-after study, women acted as own controls)

Stover 2010 Not a randomised controlled trial (pre-existing groups)

Tiwari 2010 The ’usual care’ control group received some advocacy

Trifone 1994 Not a randomised controlled trial (observational study)

Tutty 1996 Not a randomised controlled trial (before-and-after study, women acted as own controls)

Valpied 2014 Not advocacy according to our definition

Wagman 2015 Not advocacy according to our definition

Zlotnick 2011 Not advocacy according to our definition

CBT: cognitive behavioural therapy;IPV: intimate partner violence.

Characteristics of studies awaiting assessment [ordered by study ID]

Bair-Merritt 2010

Methods ND

Participants ND

Interventions ND

Outcomes ND

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intimate partner abuse (Review)
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Bair-Merritt 2010 (Continued)

Notes No data currently available for abused subset

Niolon 2009

Methods Randomised controlled trial

Participants 240 women randomly assigned to either control (home visitation program as usual) or the intervention embedded
within this

Interventions Intervention (3 components)


1. Structured assessment for intimate partner violence
2. Brochure-driven intervention for women experiencing intimate partner violence, including safety planning,
referrals and advocacy
3. Skills-based curriculum delivered to all participants that focuses on improving relationship decisions and
outcomes
Intervention delivered within a home visitation program for young, disadvantaged new mothers - the Nurse Family
Partnership (NFP), and administered at the nurse’s fourth home visit. Follow-up assessment interviews were conducted
at 1 and 2 years postintervention

Outcomes ND

Notes We contacted the author but received no reply at the time of publication

Prosman 2014

Methods ND

Participants ND

Interventions ND

Outcomes ND

Notes ND

ND: no data

Characteristics of ongoing studies [ordered by study ID]

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Lako 2013

Trial name or title The effectiveness of critical time intervention (CTI) for abused women and homeless people leaving Dutch
shelters

Methods Single-blinded, multicentre randomised controlled trial

Participants Sample size: 136 women from women’s shelters (and 183 from homeless shelters)
Setting: Shelter facilities. Facilities were eligible for selection as recruitment settings if their organisation
was participating in the Academic Collaborative Centre for Shelters and Public Mental Health in 2009.
Furthermore, shelter facilities needed to provide 24-hour services, serve at least 50 different clients aged 18 or
older per year, and expect to continue their services over the next 5 years. They also had to provide services to
clients who usually spend no longer than 12 months in the shelter facility. An additional criterion for shelter
facilities for abused women was that they needed to provide care to clients who usually spend at least 6 weeks
in the shelter. Shelter facilities were not included in the selection if their services were limited to a specific
group of clients, such as drug users or teenage mothers, or if they already offered care which was very similar
to CTI
Inclusion criteria
1. Aged 18 years or older
2. Willing to receive support from the shelter organisation during and after leaving the shelter facility
3. Staying in the shelter facility due to intimate partner or honour-related violence (abused women)
4. Had been staying in the shelter facility for at least 6 weeks (abused women)
5. Would be staying in the shelter facility for no longer than 14 months at the date of departure
(homeless people)
6. Had been given a date of departure from the shelter facility or had received a declaration of urgency
7. Were going to depart to supported or independent housing where no daily supervision or support
would be present
8. Would be required to pay rent or housing costs in their new accommodation
Exclusion criteria: were going to live in a region where none of the participating organisations provided
services
Intellectual disabilities, psychological problems, drug use or lack of command of the Dutch language did not
constitute exclusion criteria

Interventions Intervention
Critical time intervention, which is a time-limited, strengths-based psychosocial model for socially vulnerable
people, during the transition from institutional to community living. It aims provide the client with emotional
and practical support and maintain continuity of care by developing and strengthening links with people in
the client’s personal and professional support system
Control
Care-as-usual, which could include care from the shelter organisation or a referral to community services like
social services and mental health services

Outcomes Primary outcomes


1. Recurrent loss of housing, as measured by the number of days participants do not live in conventional
independent housing (property or legal (sub)tenancy) or accommodation permanently provided by friends,
relatives or acquaintances without legal (sub)tenancy during follow-up
2. Quality of life
In addition, the effect of CTI compared to care-as-usual will be determined based on the number of days
participants are in the following situations
1. Literally homeless
i) Living rough (i.e. living on the streets or in public spaces, without a shelter that can be defined as

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Lako 2013 (Continued)

living quarters)
ii) Staying temporarily in an emergency shelter or night shelter; or staying with friends, relatives, or
acquaintances
2. Institutionalised
i) Residing in transitional accommodation (where the period of stay is intended to be short-term),
residential care, or supported accommodation (long stay) for homeless people or women’s shelter
accommodation
ii) Living in residential care or supported accommodation for people with mental health or
substance abuse problems
iii) Staying in a medical institution, drug rehabilitation institution, psychiatric hospital, or
correctional or penal institution
3. Marginally housed
i) Residing in temporary accommodation, not intended as place of usual residence (hotels, motels,
inns, boarding houses, pensions, rooming houses or other lodging houses)
ii) Staying in non-conventional accommodation, not intended as place of usual residence (squatted
buildings, mobile homes, summer houses or buildings due for demolition)

Starting date December 2010 to December 2012

Contact information j.wolf@elg.umcn.nl

Notes No data currently available

NCT00465556

Trial name or title Domestic violence enhanced home visitation program - DOVE

Methods Brochure based intervention delivered by public health nurses, which aims to prevent and reduce intimate
partner violence against pregnant and postpartum women and their infants. The purpose of the study is to
test the effect of home visits on reducing domestic violence and improving the lives of pregnant women and
their children

Participants Inclusion criteria


1. Pregnant women 31 weeks or less gestation
2. Over age 18
3. History of intimate partner violence within the past 2 years
4. Willing to participate in the home visit programme

Interventions Intervention
The perinatal public health nurse home visit intervention includes a trifold brochure, printed on 8 X 10 inch
paper (203 X 254 mm, or approximately A4 size), with 6 panels, that can be read with the woman in an
interactive manner so that the woman is encouraged to describe her experiences and choose her options as
they proceed. Participants receive 3 prenatal and 3 postpartum sessions. The first prenatal sessions are given
during the first (enrolment), second, and third trimesters, with at least 3 weeks between sessions. Women
entering the study after the first trimester receive the initial session at enrolment, with 2 subsequent sessions
spread out over the remainder of the scheduled prenatal home visitation programme sessions
Control
The current protocol in use by the participating health departments when a women screens positive for

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intimate partner violence (IPV), current or historical within the last year

Outcomes Primary outcome measures


1. Reducing children’s exposure to intimate partner violence
2. Documenting patterns of intimate partner violence
3. Reducing intimate partner violence
Timing of measurement
Baseline (entry into study), birth of the infant, and 3, 6, 12, and 24 months after the
infant’s birth

Starting date February 2006-Novemeber 2011 (final registered date for completion of analyses March 31st 2015)

Contact information psharps@son.jhmi.edu

Notes Completed, insufficient data currently available

NCT01207258

Trial name or title Brief intervention for problem drinking and partner violence

Methods Longitudinal, randomised controlled trial

Participants Sample size: 600 abused women


Setting: conducted in 2 urban academic EDs staffed by emergency medicine faculty, residents, and nurse
practitioners
Inclusion criteria
1. Female patients
2. Aged 18 to 64 years
3. Presenting to 1 of 2 urban EDs
4. Able to participate verbally and cognitively in an English language interview
5. Self-disclose both heavy drinking (4 or more drinks on at least 1 day; 7 or more drinks in 1 week) and
IPV
6. Positive screen for IPV (a score of 1 or more on the CTS2) by a current or former partner in the past 3
months
Exclusion criteria
1. Intoxication at the time of screening
2. Cognitive impairment or psychosis identified on physical examination or chart review
3. Serious current medical illness or injury, defined as respiratory distress, haemodynamic instability,
active vomiting, bleeding, labor, severe pain, or acute need for hospital admission
4. Suicidal or homicidal ideation by chart review
5. No identifiable residence or contact phone number
6. Under arrest at the time of ED visit
7. Non-English speaking
8. Previously enrolled in the study

Interventions Participants are randomised into 1 of 3 study groups using a 2:2:1 distribution: Motivational Enhancement
Therapy (MET) group (n = 240), assessed control group (n = 240), and no contact control group (n = 120)
Intervention

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Receive the MET intervention - a short, 20 to 25 minute counselling session that incorporates brief feedback
and guidance with motivational enhancement techniques to assist participants in increasing their safety. The
MET intervention primarily employs motivational interviewing techniques; however, it deviates from pure
motivational interviewing by incorporating a feedback component. As with motivational interviewing, the
goal of an MET intervention is to elicit the client’s self-identified reasons for change (not the practitioner’s)
and help the client identify their own goals and resolve ambivalence. The intervention focuses on increasing
safety, spotlighting alcohol as a mediator, and connecting with further support from informal networks or
community organisations
Control
1. Assessed control group: this group does not receive the intervention and is assessed at baseline, weekly
for 12 weeks (3 months), and then at 6 and 12 months
2. No contact control group: this group does not receive the intervention and is assessed only at 3 months

Outcomes Primary outcomes


1. Episodes of heavy drinking
2. Incidents of intimate partner violence
Secondary outcomes
1. Violence severity
2. Changes in the Composite Abuse Scale (CAS)
3. Changes in alcohol quantity/frequency
4. Self-rated health, health behaviours, quality of life
5. Relationship satisfaction
Timing of measurement
1. Primary outcomes assessed weekly by Interactive Voice Response System for 12 weeks and at 3, 6 and
12 months by interviewers blinded to group assignment. To identify the impact of assessment alone, trial
includes a no-contact control group assessed only once at 3 months
2. Secondary outcomes assessed at 3, 6, and 12 months

Starting date 18 January 2011

Contact information karin.rhodes@uphs.upenn.edu

Notes The analysis will also explore the impact of likely mediators and moderators of the intervention
Ongoing, no data currently available

NCT01661504

Trial name or title Evaluating violence against women screening in Mexico

Methods Cluster-randomised controlled trial

Participants Calculated sample size: 900 women


Setting: 42 health clinics in Mexico
Inclusion criteria
1. Aged 18 to 44 years
2. Currently in a heterosexual relationship with a male partner
3. Responded in the affirmative to past year sexual or physical violence
4. Not pregnant, or pregnant in their first trimester

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5. Gave at least 1 affirmative response to the validated screening items on physical and sexual IPV an
abuse assessment screen that is widely used by International Planned Parenthood Federation/Western
Hemisphere Region (IPPF/WHR) in Latin American and Caribbean countries and has been previously used
in studies occurring in Mexico City
Exclusion criteria
1. Cognitive impairment (slurred speech, inability to follow directions)
2. Seeking treatment for life-threatening emergency care
3. Intends to relocate within 2 years

Interventions Intervention
1. Women who participated in the study at treatment clinics received the following intervention:
integrated IPV and health screening; supportive care; safety planning and harm reduction counselling;
supportive referrals; and booster counselling sessions at 3 months after baseline. The majority of materials
utilised for the intervention were adapted from existing IPPF/WHR materials used in other Latin American
and Caribbean contexts and were adapted to the characteristics of Mexico City. A referral directory was also
created with the contact information of local community agencies that provide services to IPV victims. Pilot
work revealed that women felt more comfortable asking for services if there was a specific person to contact
at an agency, and that only having the name of an agency was a deterrent
2. For endline data collection, research assistants will conduct 45 qualitative interviews with female
participants to provide insight into observed quantitative results
3. A total of 197 nurses (approximately 8% male nurses and 45% in treatment clinics) from all 42 health
clinics received the training. 147 nurses are actively participating in the study (49% in treatment clinics;
26% of staff dropped out primarily due to staff turnover at clinics). Nurses in the intervention group
received a 3-day training course that covered all the topics of the intervention, and then nurses received up
to 3 visits by research staff to practice delivering the intervention through role playing exercises individually
and in the clinics. Specific topics in the training included an introduction to IPV, health consequences of
IPV, legal considerations in Mexico City, methods to screen for violence and assess for health implications
such as reproductive coercion, safety and ethical considerations, referral methods and linkages to other
organisations in the community. An educational video modelling the counselling sessions was also
developed by the study team for the training of treatment nurses. This video was shown and discussed
during research assistant visits to the health clinics as part of the training
Control
1. Women in the control clinics were given a referral card containing general information on IPV and a
list of resources, which was consistent with the current goal for standard of care in the Mexico City Ministry
of Health. The referral card is the size of a business card so that it may easily be hidden from male partners
and is widely used in other IPV screening programmes
2. Staff in control clinics received a 1-day training session that focused mainly on sensitising nurses and
training them on using the abuse assessment. Control clinic staff will receive the intervention training upon
completion of the study
3. 15 interviews have been conducted with nurses at treatment clinics to understand their experiences
with the healthcare professional delivered approach between the 3-month follow-up period and the final
endline at 15 months

Outcomes Primary outcome measures


1. Past-year IPV
Secondary outcome measures
1. Past-year reproductive coercion
2. Use of community-based resources
3. Safety planning measures

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4. Quality of life

Starting date March 2013

Contact information jhumka.gupta@yale.edu

Notes Ongoing, no data currently available

CTS2: Short Form of the Revised Conflict Tactic Scales; ED: emergency department;IPV: intimate partner violence.

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DATA AND ANALYSES

Comparison 1. Physical abuse

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Brief advocacy 3 Std. Mean Difference (IV, Fixed, 95% CI) Subtotals only
1.1 Up to 12 months 3 558 Std. Mean Difference (IV, Fixed, 95% CI) -0.00 [-0.17, 0.16]
follow-up
1.2 12 to 24 months follow-up 1 319 Std. Mean Difference (IV, Fixed, 95% CI) -0.02 [-0.24, 0.19]
2 Brief advocacy (dichotomous 1 Odds Ratio (M-H, Fixed, 95% CI) Totals not selected
outcome) (up to 12 months
follow-up)
3 Brief advocacy (mean change) 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
3.1 ’Severe’ up to 12 months 1 110 Mean Difference (IV, Fixed, 95% CI) 0.08 [-0.26, 0.42]
follow-up
3.2 ’Minor’ up to 12 months 1 110 Mean Difference (IV, Fixed, 95% CI) -1.0 [-1.82, -0.18]
follow-up
4 Intensive advocacy 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
4.1 Up to 12 months 1 265 Mean Difference (IV, Fixed, 95% CI) -0.12 [-0.39, 0.15]
follow-up
4.2 12 to 24 months follow-up 1 265 Mean Difference (IV, Fixed, 95% CI) -0.25 [-0.50, -0.00]
4.3 24 + months follow-up 1 124 Mean Difference (IV, Fixed, 95% CI) 0.18 [-0.20, 0.56]
5 Intensive advocacy (dichotomous 2 Odds Ratio (M-H, Fixed, 95% CI) Subtotals only
outcome)
5.1 Up to 12 months 2 182 Odds Ratio (M-H, Fixed, 95% CI) 0.61 [0.33, 1.14]
follow-up
5.2 12 to 24 months follow-up 1 265 Odds Ratio (M-H, Fixed, 95% CI) 0.39 [0.20, 0.77]
5.3 24 + months follow-up 1 124 Odds Ratio (M-H, Fixed, 95% CI) 1.07 [0.52, 2.23]
6 Intensive advocacy: missing 2 Odds Ratio (M-H, Fixed, 95% CI) Subtotals only
reassigned (dichotomous
outcome) (up to 12 months
follow-up)
6.1 Missing intervention 2 192 Odds Ratio (M-H, Fixed, 95% CI) 0.54 [0.29, 1.01]
group not abused, control
group abused
6.2 Missing intervention 2 192 Odds Ratio (M-H, Fixed, 95% CI) 0.54 [0.29, 1.01]
group and control group all not
abused
6.3 Missing intervention 2 192 Odds Ratio (M-H, Fixed, 95% CI) 0.83 [0.46, 1.49]
group abused, control group
not abused
6.4 Missing intervention 2 192 Odds Ratio (M-H, Fixed, 95% CI) 0.83 [0.46, 1.49]
group and control group all
abused
7 Any advocacy 4 Std. Mean Difference (IV, Fixed, 95% CI) Subtotals only
7.1 Up to 12 months 4 823 Std. Mean Difference (IV, Fixed, 95% CI) -0.04 [-0.17, 0.10]
follow-up
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7.2 12 to 24 months follow-up 2 584 Std. Mean Difference (IV, Fixed, 95% CI) -0.12 [-0.29, 0.04]
8 Any advocacy (dichotomous 3 488 Odds Ratio (M-H, Fixed, 95% CI) 0.50 [0.33, 0.76]
outcome) (up to 12 months
follow-up)

Comparison 2. Sexual abuse

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Brief advocacy (up to 12 months 2 239 Std. Mean Difference (IV, Fixed, 95% CI) -0.12 [-0.37, 0.14]
follow-up)
2 Brief advocacy (mean change) 1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
(up to 12 months follow-up)
3 Brief advocacy (dichotomous 1 Odds Ratio (M-H, Fixed, 95% CI) Totals not selected
outcome) (up to 12 months
follow-up)

Comparison 3. Emotional abuse

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Brief advocacy 3 Std. Mean Difference (IV, Fixed, 95% CI) Subtotals only
1.1 Up to 12 months 3 558 Std. Mean Difference (IV, Fixed, 95% CI) -0.05 [-0.22, 0.11]
follow-up
1.2 12 to 24 months follow-up 1 319 Std. Mean Difference (IV, Fixed, 95% CI) -0.06 [-0.28, 0.16]
2 Brief advocacy (mean change) 1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
(up to 12 months follow-up)
3 Intensive advocacy 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
3.1 Up to 12 months 1 265 Mean Difference (IV, Fixed, 95% CI) -0.02 [-0.16, 0.12]
follow-up
3.2 12 to 24 months follow-up 1 265 Mean Difference (IV, Fixed, 95% CI) -0.04 [-0.19, 0.11]
4 Intensive advocacy (dichotomous 1 Odds Ratio (M-H, Fixed, 95% CI) Totals not selected
outcome) (up to 12 months
follow-up)
5 Any advocacy 4 Std. Mean Difference (IV, Fixed, 95% CI) Subtotals only
5.1 Up to 12 months 4 823 Std. Mean Difference (IV, Fixed, 95% CI) -0.05 [-0.18, 0.09]
follow-up
5.2 12 to 24 months follow-up 2 584 Std. Mean Difference (IV, Fixed, 95% CI) -0.06 [-0.22, 0.10]

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Comparison 4. Risk of homicide

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Brief advocacy 2 Mean Difference (IV, Fixed, 95% CI) Subtotals only
1.1 Up to 12 months 2 358 Mean Difference (IV, Fixed, 95% CI) 0.13 [-0.54, 0.80]
follow-up
1.2 12 to 24 months follow-up 1 319 Mean Difference (IV, Fixed, 95% CI) -0.30 [-1.07, 0.47]

Comparison 5. Risk of work harassment

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Brief advocacy 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
1.1 Up to 12 months 1 319 Mean Difference (IV, Fixed, 95% CI) 0.10 [-0.36, 0.56]
follow-up
1.2 12 to 24 months follow-up 1 319 Mean Difference (IV, Fixed, 95% CI) -0.60 [-0.97, -0.23]

Comparison 6. Overall abuse

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Brief advocacy (up to 12 months 1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
follow-up)
2 Intensive advocacy (up to 12 2 Std. Mean Difference (IV, Fixed, 95% CI) Totals not selected
months follow-up)
3 Intensive advocacy (dichotomous 1 Odds Ratio (M-H, Fixed, 95% CI) Totals not selected
outcome) (up to 12 months
follow-up)
4 Any advocacy (up to 12 months 3 234 Std. Mean Difference (IV, Fixed, 95% CI) -0.26 [-0.52, 0.01]
follow-up)

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Comparison 7. Quality of life

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Brief advocacy: 2 summary 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
component subscales
1.1 Physical component up to 1 200 Mean Difference (IV, Fixed, 95% CI) 0.80 [-1.27, 2.87]
12 months follow-up
1.2 Mental component up to 1 200 Mean Difference (IV, Fixed, 95% CI) 0.37 [-1.94, 2.68]
12 months follow-up
2 Brief advocacy: 8 subscales 2 Mean Difference (IV, Fixed, 95% CI) Subtotals only
(mean change)
2.1 Physical functioning up to 2 314 Mean Difference (IV, Fixed, 95% CI) 4.92 [-0.32, 10.16]
12 months follow-up
2.2 Role physical up to 12 2 314 Mean Difference (IV, Fixed, 95% CI) 7.42 [-0.97, 15.80]
months follow-up
2.3 Bodily pain up to 12 2 314 Mean Difference (IV, Fixed, 95% CI) -4.51 [-10.42, 1.39]
months follow-up
2.4 General health up to 12 2 314 Mean Difference (IV, Fixed, 95% CI) -0.85 [-4.06, 2.37]
months follow-up
2.5 Vitality up to 12 months 2 314 Mean Difference (IV, Fixed, 95% CI) -1.38 [-5.56, 2.80]
follow-up
2.6 Social functioning up to 2 314 Mean Difference (IV, Fixed, 95% CI) 0.92 [-5.00, 6.84]
12 months follow-up
2.7 Role emotional up to 12 2 314 Mean Difference (IV, Fixed, 95% CI) 9.37 [-0.31, 19.05]
months follow-up
2.8 Mental health up to 12 2 314 Mean Difference (IV, Fixed, 95% CI) -1.72 [-5.31, 1.87]
months follow-up
3 Intensive advocacy: 2 summary 1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
component subscales
3.1 Physical component up to 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
12 months follow-up
3.2 Mental component up to 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
12 months follow-up
4 Intensive advocacy: overall 2 Mean Difference (IV, Fixed, 95% CI) Subtotals only
4.1 Up to 12 months 2 343 Mean Difference (IV, Fixed, 95% CI) 0.23 [0.00, 0.46]
follow-up
4.2 12 to 24 months follow-up 1 265 Mean Difference (IV, Fixed, 95% CI) 0.25 [-0.02, 0.52]
4.3 24 + months follow-up 1 124 Mean Difference (IV, Fixed, 95% CI) 0.30 [-0.07, 0.67]
5 Any advocacy: 2 summary 2 Std. Mean Difference (IV, Fixed, 95% CI) Subtotals only
component subscales
5.1 Physical component up to 2 303 Std. Mean Difference (IV, Fixed, 95% CI) 0.21 [-0.02, 0.44]
12 months follow-up
5.2 Mental component up to 2 303 Std. Mean Difference (IV, Fixed, 95% CI) 0.08 [-0.15, 0.31]
12 months

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Comparison 8. Depression

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Brief advocacy (up to 12 months 2 239 Std. Mean Difference (IV, Fixed, 95% CI) -0.17 [-0.43, 0.08]
follow-up)
2 Brief advocacy (dichotomous 2 149 Odds Ratio (M-H, Fixed, 95% CI) 0.31 [0.15, 0.65]
outcome) (up to 12 months
follow-up)
3 Intensive advocacy 3 Std. Mean Difference (IV, Fixed, 95% CI) Subtotals only
3.1 Up to 12 months 3 446 Std. Mean Difference (IV, Fixed, 95% CI) -0.14 [-0.33, 0.05]
follow-up
3.2 12 to 24 months follow-up 1 265 Std. Mean Difference (IV, Fixed, 95% CI) -0.12 [-0.36, 0.12]
4 Intensive advocacy (dichotomous 1 Odds Ratio (M-H, Fixed, 95% CI) Totals not selected
outcome) (up to 12 months
follow-up)
5 Any advocacy (up to 12 months 5 685 Std. Mean Difference (IV, Fixed, 95% CI) -0.15 [-0.30, 0.00]
follow-up)
6 Any advocacy (dichotomous 3 252 Odds Ratio (M-H, Fixed, 95% CI) 0.37 [0.21, 0.66]
outcome) (up to 12 months
follow-up)

Comparison 9. Anxiety

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Brief advocacy (up to 12 months 1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
follow-up)
2 Intensive advocacy 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
2.1 Up to 12 months 1 265 Mean Difference (IV, Fixed, 95% CI) -0.13 [-0.35, 0.09]
follow-up
2.2 12 to 24 months follow-up 1 265 Mean Difference (IV, Fixed, 95% CI) -0.01 [-0.22, 0.20]
2.3 24 + months follow-up 1 124 Mean Difference (IV, Fixed, 95% CI) -0.11 [-0.40, 0.18]
3 Intensive advocacy (mean 1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
change) (up to 12 months
follow-up)
4 Any advocacy (up to 12 months 2 318 Std. Mean Difference (IV, Fixed, 95% CI) -0.22 [-0.44, 0.01]
follow-up)

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Comparison 10. Chronic pain

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Brief advocacy (up to 12 months 1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
follow-up)

Comparison 11. Chronic fatigue

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Brief advocacy (up to 12 months 1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
follow-up)

Comparison 12. Low birth weight

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Brief advocacy (dichotomous 1 Odds Ratio (M-H, Fixed, 95% CI) Totals not selected
outcome)
1.1 Low birth weight (< 2500 1 Odds Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
g)
1.2 Very low birth weight (< 1 Odds Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
1500 g)

Comparison 13. Birth weight (grams)

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Brief advocacy 1 Mean Difference (IV, Fixed, 95% CI) Totals not selected

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Comparison 14. Pre-term birth

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Brief advocacy (dichotomous 1 Odds Ratio (M-H, Fixed, 95% CI) Totals not selected
outcome)
1.1 Pre-term birth (37 weeks 1 Odds Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
gestation)
1.2 Very pre-term birth (< 33 1 Odds Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
weeks gestation)

Comparison 15. Gestational age (weeks) at delivery

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Brief advocacy 1 Mean Difference (IV, Fixed, 95% CI) Totals not selected

Comparison 16. Post-traumatic stress

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Brief advocacy (up to 12 months 2 92 Std. Mean Difference (IV, Fixed, 95% CI) -0.21 [-0.62, 0.21]
follow-up)

Comparison 17. Perception of stress

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Brief advocacy (up to 12 months 1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
follow-up)

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 100
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Comparison 18. Self efficacy

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Intensive advocacy 1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
1.1 Up to 12 months 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
follow-up
1.2 12 to 24 months follow-up 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
1.3 24 + months follow-up 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]

Comparison 19. Self esteem

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Intensive advocacy (up to 12 1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
months follow-up)

Comparison 20. Perceived social support

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Brief advocacy (up to 12 months 1 Mean Difference (IV, Fixed, 95% CI) Totals not selected
follow-up)
2 Intensive advocacy 3 Std. Mean Difference (IV, Fixed, 95% CI) Subtotals only
2.1 Up to 12 months 3 446 Std. Mean Difference (IV, Fixed, 95% CI) 0.00 [-0.19, 0.19]
follow-up
2.2 12 to 24 months follow-up 1 265 Std. Mean Difference (IV, Fixed, 95% CI) 0.12 [-0.12, 0.37]
2.3 24 + months follow-up 1 124 Std. Mean Difference (IV, Fixed, 95% CI) 0.39 [0.03, 0.74]
3 Intensive advocacy (mean 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
change)
3.1 Overall support up to 12 1 24 Mean Difference (IV, Fixed, 95% CI) 10.19 [5.67, 14.71]
months follow-up
3.2 Tangible support up to 12 1 24 Mean Difference (IV, Fixed, 95% CI) 2.19 [0.93, 3.45]
months follow-up
3.3 Appraisal support up to 1 24 Mean Difference (IV, Fixed, 95% CI) 0.67 [0.14, 1.20]
12 months follow-up
3.4 Self esteem support up to 1 24 Mean Difference (IV, Fixed, 95% CI) 1.14 [0.43, 1.85]
12 months follow-up
3.5 Belonging support up to 1 24 Mean Difference (IV, Fixed, 95% CI) 4.18 [1.18, 7.18]
12 months follow-up
4 Any advocacy (up to 12 months 4 646 Std. Mean Difference (IV, Fixed, 95% CI) 0.07 [-0.08, 0.23]
follow-up)

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 101
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Comparison 21. Independence from abuser

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Intensive advocacy (dichotomous 2 Odds Ratio (M-H, Fixed, 95% CI) Subtotals only
outcome)
1.1 Up to 12 months 2 301 Odds Ratio (M-H, Fixed, 95% CI) 1.22 [0.74, 2.00]
follow-up
1.2 12 to 24 months follow-up 1 261 Odds Ratio (M-H, Fixed, 95% CI) 1.27 [0.78, 2.08]
1.3 24 + months follow-up 1 119 Odds Ratio (M-H, Fixed, 95% CI) 0.97 [0.47, 1.98]
2 Intensive advocacy: missing 2 Odds Ratio (M-H, Fixed, 95% CI) Subtotals only
reassigned (up to 12 months
follow-up) (dichotomous
outcome)
2.1 Missing intervention 2 330 Odds Ratio (M-H, Fixed, 95% CI) 1.58 [0.98, 2.55]
group independent, control
group not independent
2.2 Missing intervention 2 330 Odds Ratio (M-H, Fixed, 95% CI) 1.13 [0.71, 1.80]
group and control group all
independent
2.3 Missing intervention 2 330 Odds Ratio (M-H, Fixed, 95% CI) 0.82 [0.52, 1.31]
group not independent, control
group independent
2.4 Missing intervention 2 330 Odds Ratio (M-H, Fixed, 95% CI) 1.13 [0.70, 1.82]
group and control group all not
independent

Comparison 22. Emotional attachment to abuser

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Intensive advocacy 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
1.1 Up to 12 months 1 265 Mean Difference (IV, Fixed, 95% CI) -0.02 [-0.08, 0.04]
follow-up
1.2 12 to 24 months follow-up 1 265 Mean Difference (IV, Fixed, 95% CI) 0.0 [-0.05, 0.05]
1.3 24 + months follow-up 1 124 Mean Difference (IV, Fixed, 95% CI) -0.07 [-0.14, -.00]

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 102
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Comparison 23. Use of safety behaviours

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Brief advocacy 3 Mean Difference (IV, Fixed, 95% CI) Subtotals only
1.1 Up to 12 months 3 558 Mean Difference (IV, Fixed, 95% CI) 1.39 [0.92, 1.87]
follow-up
1.2 12 to 24 months follow-up 1 319 Mean Difference (IV, Fixed, 95% CI) 0.10 [-0.42, 0.62]

Comparison 24. Use of resources

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Brief advocacy 2 Std. Mean Difference (IV, Fixed, 95% CI) Subtotals only
1.1 Up to 12 months 2 358 Std. Mean Difference (IV, Fixed, 95% CI) 0.19 [-0.02, 0.39]
follow-up
1.2 12 to 24 months follow-up 1 319 Std. Mean Difference (IV, Fixed, 95% CI) 0.15 [-0.07, 0.37]

Comparison 25. Difficulty obtaining resources

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Intensive advocacy 1 Mean Difference (IV, Fixed, 95% CI) Totals not selected

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 103
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.1. Comparison 1 Physical abuse, Outcome 1 Brief advocacy.

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

Comparison: 1 Physical abuse

Outcome: 1 Brief advocacy

Std. Std.
Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 Up to 12 months follow-up
Gillum 2009 19 0.63 (2.1) 20 0.45 (1.1) 7.0 % 0.11 [ -0.52, 0.73 ]

McFarlane 2006 161 13.7 (15.3) 158 12.6 (14.5) 57.2 % 0.07 [ -0.15, 0.29 ]

Tiwari 2010 100 0.23 (1.27) 100 0.45 (1.74) 35.8 % -0.14 [ -0.42, 0.13 ]

Subtotal (95% CI) 280 278 100.0 % 0.00 [ -0.17, 0.16 ]


Heterogeneity: Chi2 = 1.57, df = 2 (P = 0.46); I2 =0.0%
Test for overall effect: Z = 0.02 (P = 0.98)
2 12 to 24 months follow-up
McFarlane 2006 161 7.6 (12.2) 158 7.9 (12.1) 100.0 % -0.02 [ -0.24, 0.19 ]

Subtotal (95% CI) 161 158 100.0 % -0.02 [ -0.24, 0.19 ]


Heterogeneity: not applicable
Test for overall effect: Z = 0.22 (P = 0.83)

-1 -0.5 0 0.5 1
Favours intervention Favours control

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intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.2. Comparison 1 Physical abuse, Outcome 2 Brief advocacy (dichotomous outcome) (up to 12
months follow-up).

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

Comparison: 1 Physical abuse

Outcome: 2 Brief advocacy (dichotomous outcome) (up to 12 months follow-up)

Study or subgroup Intervention Control Odds Ratio Odds Ratio


n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Kiely 2010 20/150 42/156 0.42 [ 0.23, 0.75 ]

0.2 0.5 1 2 5
Favours intervention Favours control

Analysis 1.3. Comparison 1 Physical abuse, Outcome 3 Brief advocacy (mean change).

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

Comparison: 1 Physical abuse

Outcome: 3 Brief advocacy (mean change)

Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 ’Severe’ up to 12 months follow-up


Tiwari 2005 55 0.25 (1.15) 55 0.17 (0.54) 100.0 % 0.08 [ -0.26, 0.42 ]

Subtotal (95% CI) 55 55 100.0 % 0.08 [ -0.26, 0.42 ]


Heterogeneity: not applicable
Test for overall effect: Z = 0.47 (P = 0.64)
2 ’Minor’ up to 12 months follow-up
Tiwari 2005 55 -1.2 (2.72) 55 -0.2 (1.5) 100.0 % -1.00 [ -1.82, -0.18 ]

Subtotal (95% CI) 55 55 100.0 % -1.00 [ -1.82, -0.18 ]


Heterogeneity: not applicable
Test for overall effect: Z = 2.39 (P = 0.017)

-2 -1 0 1 2
Favours intervention Favours control

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 105
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.4. Comparison 1 Physical abuse, Outcome 4 Intensive advocacy.

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

Comparison: 1 Physical abuse

Outcome: 4 Intensive advocacy

Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 Up to 12 months follow-up
Sullivan 1992 135 0.88 (1.07) 130 1 (1.14) 100.0 % -0.12 [ -0.39, 0.15 ]

Subtotal (95% CI) 135 130 100.0 % -0.12 [ -0.39, 0.15 ]


Heterogeneity: not applicable
Test for overall effect: Z = 0.88 (P = 0.38)
2 12 to 24 months follow-up
Sullivan 1992 135 0.6 (0.99) 130 0.85 (1.07) 100.0 % -0.25 [ -0.50, 0.00 ]

Subtotal (95% CI) 135 130 100.0 % -0.25 [ -0.50, 0.00 ]


Heterogeneity: not applicable
Test for overall effect: Z = 1.97 (P = 0.049)
3 24 + months follow-up
Sullivan 1992 62 0.84 (1.19) 62 0.66 (0.97) 100.0 % 0.18 [ -0.20, 0.56 ]

Subtotal (95% CI) 62 62 100.0 % 0.18 [ -0.20, 0.56 ]


Heterogeneity: not applicable
Test for overall effect: Z = 0.92 (P = 0.36)

-1 -0.5 0 0.5 1
Favours intervention Favours control

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intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.5. Comparison 1 Physical abuse, Outcome 5 Intensive advocacy (dichotomous outcome).

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

Comparison: 1 Physical abuse

Outcome: 5 Intensive advocacy (dichotomous outcome)

Study or subgroup Intervention Control Odds Ratio Weight Odds Ratio


n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

1 Up to 12 months follow-up
Sullivan 1991 3/25 3/16 12.8 % 0.59 [ 0.10, 3.37 ]

Sullivan 1992 28/71 36/70 87.2 % 0.61 [ 0.32, 1.20 ]

Subtotal (95% CI) 96 86 100.0 % 0.61 [ 0.33, 1.14 ]


Total events: 31 (Intervention), 39 (Control)
Heterogeneity: Chi2 = 0.00, df = 1 (P = 0.97); I2 =0.0%
Test for overall effect: Z = 1.54 (P = 0.12)
2 12 to 24 months follow-up
Sullivan 1992 103/135 116/130 100.0 % 0.39 [ 0.20, 0.77 ]

Subtotal (95% CI) 135 130 100.0 % 0.39 [ 0.20, 0.77 ]


Total events: 103 (Intervention), 116 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 2.72 (P = 0.0066)
3 24 + months follow-up
Sullivan 1992 23/62 22/62 100.0 % 1.07 [ 0.52, 2.23 ]

Subtotal (95% CI) 62 62 100.0 % 1.07 [ 0.52, 2.23 ]


Total events: 23 (Intervention), 22 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.19 (P = 0.85)

0.1 0.2 0.5 1 2 5 10


Favours intervention Favours control

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 107
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.6. Comparison 1 Physical abuse, Outcome 6 Intensive advocacy: missing reassigned
(dichotomous outcome) (up to 12 months follow-up).

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

Comparison: 1 Physical abuse

Outcome: 6 Intensive advocacy: missing reassigned (dichotomous outcome) (up to 12 months follow-up)

Study or subgroup Intervention Control Odds Ratio Weight Odds Ratio


n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

1 Missing intervention group not abused, control group abused


Sullivan 1991 3/30 3/16 13.0 % 0.48 [ 0.09, 2.72 ]

Sullivan 1992 28/76 36/70 87.0 % 0.55 [ 0.28, 1.07 ]

Subtotal (95% CI) 106 86 100.0 % 0.54 [ 0.29, 1.01 ]


Total events: 31 (Intervention), 39 (Control)
Heterogeneity: Chi2 = 0.02, df = 1 (P = 0.89); I2 =0.0%
Test for overall effect: Z = 1.94 (P = 0.052)
2 Missing intervention group and control group all not abused
Sullivan 1991 3/30 3/16 13.0 % 0.48 [ 0.09, 2.72 ]

Sullivan 1992 28/76 36/70 87.0 % 0.55 [ 0.28, 1.07 ]

Subtotal (95% CI) 106 86 100.0 % 0.54 [ 0.29, 1.01 ]


Total events: 31 (Intervention), 39 (Control)
Heterogeneity: Chi2 = 0.02, df = 1 (P = 0.89); I2 =0.0%
Test for overall effect: Z = 1.94 (P = 0.052)
3 Missing intervention group abused, control group not abused
Sullivan 1991 8/30 3/16 11.9 % 1.58 [ 0.35, 7.02 ]

Sullivan 1992 33/76 36/70 88.1 % 0.72 [ 0.38, 1.39 ]

Subtotal (95% CI) 106 86 100.0 % 0.83 [ 0.46, 1.49 ]


Total events: 41 (Intervention), 39 (Control)
Heterogeneity: Chi2 = 0.87, df = 1 (P = 0.35); I2 =0.0%
Test for overall effect: Z = 0.63 (P = 0.53)
4 Missing intervention group and control group all abused
Sullivan 1991 8/30 3/16 11.9 % 1.58 [ 0.35, 7.02 ]

Sullivan 1992 33/76 36/70 88.1 % 0.72 [ 0.38, 1.39 ]

Subtotal (95% CI) 106 86 100.0 % 0.83 [ 0.46, 1.49 ]


Total events: 41 (Intervention), 39 (Control)
Heterogeneity: Chi2 = 0.87, df = 1 (P = 0.35); I2 =0.0%
Test for overall effect: Z = 0.63 (P = 0.53)

0.01 0.1 1 10 100


Favours intervention Favours control

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intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.7. Comparison 1 Physical abuse, Outcome 7 Any advocacy.

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

Comparison: 1 Physical abuse

Outcome: 7 Any advocacy

Std. Std.
Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 Up to 12 months follow-up
Gillum 2009 19 0.63 (2.1) 20 0.45 (1.1) 4.7 % 0.11 [ -0.52, 0.73 ]

McFarlane 2006 161 13.7 (15.3) 158 12.6 (14.5) 38.8 % 0.07 [ -0.15, 0.29 ]

Sullivan 1992 135 0.88 (1.07) 130 1 (1.14) 32.2 % -0.11 [ -0.35, 0.13 ]

Tiwari 2010 100 0.23 (1.27) 100 0.45 (1.74) 24.3 % -0.14 [ -0.42, 0.13 ]

Subtotal (95% CI) 415 408 100.0 % -0.04 [ -0.17, 0.10 ]


Heterogeneity: Chi2 = 2.08, df = 3 (P = 0.56); I2 =0.0%
Test for overall effect: Z = 0.52 (P = 0.60)
2 12 to 24 months follow-up
McFarlane 2006 161 7.6 (12.2) 158 7.9 (12.1) 54.8 % -0.02 [ -0.24, 0.19 ]

Sullivan 1992 135 0.6 (0.99) 130 0.85 (1.07) 45.2 % -0.24 [ -0.48, 0.00 ]

Subtotal (95% CI) 296 288 100.0 % -0.12 [ -0.29, 0.04 ]


Heterogeneity: Chi2 = 1.70, df = 1 (P = 0.19); I2 =41%
Test for overall effect: Z = 1.48 (P = 0.14)

-1 -0.5 0 0.5 1
Favours intervention Favours control

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 109
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 1.8. Comparison 1 Physical abuse, Outcome 8 Any advocacy (dichotomous outcome) (up to 12
months follow-up).

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

Comparison: 1 Physical abuse

Outcome: 8 Any advocacy (dichotomous outcome) (up to 12 months follow-up)

Study or subgroup Intervention Control Odds Ratio Weight Odds Ratio


n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Kiely 2010 20/150 42/156 58.6 % 0.42 [ 0.23, 0.75 ]

Sullivan 1991 3/25 3/16 5.3 % 0.59 [ 0.10, 3.37 ]

Sullivan 1992 28/71 36/70 36.1 % 0.61 [ 0.32, 1.20 ]

Total (95% CI) 246 242 100.0 % 0.50 [ 0.33, 0.76 ]


Total events: 51 (Intervention), 81 (Control)
Heterogeneity: Chi2 = 0.76, df = 2 (P = 0.68); I2 =0.0%
Test for overall effect: Z = 3.21 (P = 0.0013)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10


Favours intervention Favours control

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 110
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 2.1. Comparison 2 Sexual abuse, Outcome 1 Brief advocacy (up to 12 months follow-up).

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

Comparison: 2 Sexual abuse

Outcome: 1 Brief advocacy (up to 12 months follow-up)

Std. Std.
Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Gillum 2009 19 0.2 (0.4) 20 0.1 (0.3) 16.2 % 0.28 [ -0.35, 0.91 ]

Tiwari 2010 100 0.03 (0.3) 100 0.14 (0.75) 83.8 % -0.19 [ -0.47, 0.09 ]

Total (95% CI) 119 120 100.0 % -0.12 [ -0.37, 0.14 ]


Heterogeneity: Chi2 = 1.78, df = 1 (P = 0.18); I2 =44%
Test for overall effect: Z = 0.89 (P = 0.37)
Test for subgroup differences: Not applicable

-1 -0.5 0 0.5 1
Favours intervention Favours control

Analysis 2.2. Comparison 2 Sexual abuse, Outcome 2 Brief advocacy (mean change) (up to 12 months
follow-up).

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

Comparison: 2 Sexual abuse

Outcome: 2 Brief advocacy (mean change) (up to 12 months follow-up)

Mean Mean
Study or subgroup Intervention Control Difference Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Tiwari 2005 55 -0.13 (0.59) 55 -0.06 (0.62) -0.07 [ -0.30, 0.16 ]

-0.5 -0.25 0 0.25 0.5


Favours intervention Favours control

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intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 2.3. Comparison 2 Sexual abuse, Outcome 3 Brief advocacy (dichotomous outcome) (up to 12
months follow-up).

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

Comparison: 2 Sexual abuse

Outcome: 3 Brief advocacy (dichotomous outcome) (up to 12 months follow-up)

Study or subgroup Intervention Control Odds Ratio Odds Ratio


n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Kiely 2010 13/150 14/156 0.96 [ 0.44, 2.12 ]

0.2 0.5 1 2 5
Favours intervention Favours control

Analysis 3.1. Comparison 3 Emotional abuse, Outcome 1 Brief advocacy.

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

Comparison: 3 Emotional abuse

Outcome: 1 Brief advocacy

Std. Std.
Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 Up to 12 months follow-up
Gillum 2009 19 22.2 (33.1) 20 24.8 (32.3) 7.0 % -0.08 [ -0.71, 0.55 ]

McFarlane 2006 161 15.7 (13.3) 158 14.5 (13.4) 57.3 % 0.09 [ -0.13, 0.31 ]

Tiwari 2010 100 10.07 (5.91) 100 12.11 (8.57) 35.6 % -0.28 [ -0.55, 0.00 ]

Subtotal (95% CI) 280 278 100.0 % -0.05 [ -0.22, 0.11 ]


Heterogeneity: Chi2 = 4.09, df = 2 (P = 0.13); I2 =51%
Test for overall effect: Z = 0.62 (P = 0.54)
2 12 to 24 months follow-up
McFarlane 2006 161 8.9 (11.6) 158 9.6 (11.7) 100.0 % -0.06 [ -0.28, 0.16 ]

Subtotal (95% CI) 161 158 100.0 % -0.06 [ -0.28, 0.16 ]


Heterogeneity: not applicable
Test for overall effect: Z = 0.54 (P = 0.59)

-1 -0.5 0 0.5 1
Favours intervention Favours control

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intimate partner abuse (Review)
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Analysis 3.2. Comparison 3 Emotional abuse, Outcome 2 Brief advocacy (mean change) (up to 12 months
follow-up).

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

Comparison: 3 Emotional abuse

Outcome: 2 Brief advocacy (mean change) (up to 12 months follow-up)

Mean Mean
Study or subgroup Intervention Control Difference Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Tiwari 2005 55 -6.16 (5.88) 55 -1.92 (5.78) -4.24 [ -6.42, -2.06 ]

-10 -5 0 5 10
Favours intervention Favours control

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 113
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 3.3. Comparison 3 Emotional abuse, Outcome 3 Intensive advocacy.

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

Comparison: 3 Emotional abuse

Outcome: 3 Intensive advocacy

Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 Up to 12 months follow-up
Sullivan 1992 135 1.42 (0.61) 130 1.44 (0.58) 100.0 % -0.02 [ -0.16, 0.12 ]

Subtotal (95% CI) 135 130 100.0 % -0.02 [ -0.16, 0.12 ]


Heterogeneity: not applicable
Test for overall effect: Z = 0.27 (P = 0.78)
2 12 to 24 months follow-up
Sullivan 1992 135 1.36 (0.63) 130 1.4 (0.58) 100.0 % -0.04 [ -0.19, 0.11 ]

Subtotal (95% CI) 135 130 100.0 % -0.04 [ -0.19, 0.11 ]


Heterogeneity: not applicable
Test for overall effect: Z = 0.54 (P = 0.59)

-0.5 -0.25 0 0.25 0.5


Favours intervention Favours control

Analysis 3.4. Comparison 3 Emotional abuse, Outcome 4 Intensive advocacy (dichotomous outcome) (up
to 12 months follow-up).

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

Comparison: 3 Emotional abuse

Outcome: 4 Intensive advocacy (dichotomous outcome) (up to 12 months follow-up)

Study or subgroup Intervention Control Odds Ratio Odds Ratio


n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Sullivan 1992 30/71 39/70 0.58 [ 0.30, 1.13 ]

0.2 0.5 1 2 5
Favours intervention Favours control

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 114
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 3.5. Comparison 3 Emotional abuse, Outcome 5 Any advocacy.

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

Comparison: 3 Emotional abuse

Outcome: 5 Any advocacy

Std. Std.
Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 Up to 12 months follow-up
Gillum 2009 19 22.2 (33.1) 20 24.8 (32.3) 4.7 % -0.08 [ -0.71, 0.55 ]

McFarlane 2006 161 15.7 (13.3) 158 14.5 (13.4) 38.8 % 0.09 [ -0.13, 0.31 ]

Sullivan 1992 135 1.42 (0.61) 130 1.44 (0.58) 32.3 % -0.03 [ -0.27, 0.21 ]

Tiwari 2010 100 10.07 (5.91) 100 12.11 (8.57) 24.1 % -0.28 [ -0.55, 0.00 ]

Subtotal (95% CI) 415 408 100.0 % -0.05 [ -0.18, 0.09 ]


Heterogeneity: Chi2 = 4.11, df = 3 (P = 0.25); I2 =27%
Test for overall effect: Z = 0.66 (P = 0.51)
2 12 to 24 months follow-up
McFarlane 2006 161 8.9 (11.6) 158 9.6 (11.7) 54.6 % -0.06 [ -0.28, 0.16 ]

Sullivan 1992 135 1.36 (0.63) 130 1.4 (0.58) 45.4 % -0.07 [ -0.31, 0.18 ]

Subtotal (95% CI) 296 288 100.0 % -0.06 [ -0.22, 0.10 ]


Heterogeneity: Chi2 = 0.00, df = 1 (P = 0.97); I2 =0.0%
Test for overall effect: Z = 0.76 (P = 0.45)

-0.5 -0.25 0 0.25 0.5


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Analysis 4.1. Comparison 4 Risk of homicide, Outcome 1 Brief advocacy.

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

Comparison: 4 Risk of homicide

Outcome: 1 Brief advocacy

Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 Up to 12 months follow-up
Gillum 2009 19 1.8 (2.2) 20 1.6 (1.6) 30.4 % 0.20 [ -1.01, 1.41 ]

McFarlane 2006 161 4.9 (3.7) 158 4.8 (3.6) 69.6 % 0.10 [ -0.70, 0.90 ]

Subtotal (95% CI) 180 178 100.0 % 0.13 [ -0.54, 0.80 ]


Heterogeneity: Chi2 = 0.02, df = 1 (P = 0.89); I2 =0.0%
Test for overall effect: Z = 0.38 (P = 0.70)
2 12 to 24 months follow-up
McFarlane 2006 161 3.4 (3.4) 158 3.7 (3.6) 100.0 % -0.30 [ -1.07, 0.47 ]

Subtotal (95% CI) 161 158 100.0 % -0.30 [ -1.07, 0.47 ]


Heterogeneity: not applicable
Test for overall effect: Z = 0.76 (P = 0.44)
Test for subgroup differences: Chi2 = 0.69, df = 1 (P = 0.41), I2 =0.0%

-2 -1 0 1 2
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Analysis 5.1. Comparison 5 Risk of work harassment, Outcome 1 Brief advocacy.

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

Comparison: 5 Risk of work harassment

Outcome: 1 Brief advocacy

Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 Up to 12 months follow-up
McFarlane 2006 161 1.9 (2.1) 158 1.8 (2.1) 100.0 % 0.10 [ -0.36, 0.56 ]

Subtotal (95% CI) 161 158 100.0 % 0.10 [ -0.36, 0.56 ]


Heterogeneity: not applicable
Test for overall effect: Z = 0.43 (P = 0.67)
2 12 to 24 months follow-up
McFarlane 2006 161 0.7 (1.4) 158 1.3 (1.9) 100.0 % -0.60 [ -0.97, -0.23 ]

Subtotal (95% CI) 161 158 100.0 % -0.60 [ -0.97, -0.23 ]


Heterogeneity: not applicable
Test for overall effect: Z = 3.21 (P = 0.0013)

-2 -1 0 1 2
Favours intervention Favours control

Analysis 6.1. Comparison 6 Overall abuse, Outcome 1 Brief advocacy (up to 12 months follow-up).

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

Comparison: 6 Overall abuse

Outcome: 1 Brief advocacy (up to 12 months follow-up)

Mean Mean
Study or subgroup Intervention Control Difference Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Hyman 2001 31 15.65 (19.43) 22 23.39 (25.3) -7.74 [ -20.33, 4.85 ]

-20 -10 0 10 20
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Analysis 6.2. Comparison 6 Overall abuse, Outcome 2 Intensive advocacy (up to 12 months follow-up).

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

Comparison: 6 Overall abuse

Outcome: 2 Intensive advocacy (up to 12 months follow-up)

Std. Std.
Mean Mean
Study or subgroup Intervention Control Difference Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Sullivan 2002 45 0.6 (0.69) 33 0.58 (0.68) 0.03 [ -0.42, 0.48 ]

Taft 2011 71 17.6 (16.7) 32 27.1 (27.9) -0.45 [ -0.88, -0.03 ]

-1 -0.5 0 0.5 1
Favours intervention Favours control

Analysis 6.3. Comparison 6 Overall abuse, Outcome 3 Intensive advocacy (dichotomous outcome) (up to
12 months follow-up).

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

Comparison: 6 Overall abuse

Outcome: 3 Intensive advocacy (dichotomous outcome) (up to 12 months follow-up)

Study or subgroup Intervention Control Odds Ratio Odds Ratio


n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Taft 2011 46/71 23/32 0.72 [ 0.29, 1.79 ]

0.2 0.5 1 2 5
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Analysis 6.4. Comparison 6 Overall abuse, Outcome 4 Any advocacy (up to 12 months follow-up).

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

Comparison: 6 Overall abuse

Outcome: 4 Any advocacy (up to 12 months follow-up)

Std. Std.
Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Hyman 2001 31 15.65 (19.43) 22 23.39 (25.3) 23.8 % -0.35 [ -0.90, 0.20 ]

Sullivan 2002 45 0.6 (0.69) 33 0.58 (0.68) 35.7 % 0.03 [ -0.42, 0.48 ]

Taft 2011 71 17.6 (16.7) 32 27.1 (27.9) 40.5 % -0.45 [ -0.88, -0.03 ]

Total (95% CI) 147 87 100.0 % -0.26 [ -0.52, 0.01 ]


Heterogeneity: Chi2 = 2.49, df = 2 (P = 0.29); I2 =20%
Test for overall effect: Z = 1.87 (P = 0.062)
Test for subgroup differences: Not applicable

-1 -0.5 0 0.5 1
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Analysis 7.1. Comparison 7 Quality of life, Outcome 1 Brief advocacy: 2 summary component subscales.

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

Comparison: 7 Quality of life

Outcome: 1 Brief advocacy: 2 summary component subscales

Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 Physical component up to 12 months follow-up


Tiwari 2010 100 44.35 (7.64) 100 43.55 (7.3) 100.0 % 0.80 [ -1.27, 2.87 ]

Subtotal (95% CI) 100 100 100.0 % 0.80 [ -1.27, 2.87 ]


Heterogeneity: not applicable
Test for overall effect: Z = 0.76 (P = 0.45)
2 Mental component up to 12 months follow-up
Tiwari 2010 100 38.26 (8.56) 100 37.89 (8.08) 100.0 % 0.37 [ -1.94, 2.68 ]

Subtotal (95% CI) 100 100 100.0 % 0.37 [ -1.94, 2.68 ]


Heterogeneity: not applicable
Test for overall effect: Z = 0.31 (P = 0.75)

-4 -2 0 2 4
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Analysis 7.2. Comparison 7 Quality of life, Outcome 2 Brief advocacy: 8 subscales (mean change).

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

Comparison: 7 Quality of life

Outcome: 2 Brief advocacy: 8 subscales (mean change)

Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 Physical functioning up to 12 months follow-up


Cripe 2010 104 15.67 (28.35) 100 15.7 (25.06) 51.1 % -0.03 [ -7.37, 7.31 ]

Tiwari 2005 55 9.91 (19.11) 55 -0.18 (20.97) 48.9 % 10.09 [ 2.59, 17.59 ]

Subtotal (95% CI) 159 155 100.0 % 4.92 [ -0.32, 10.16 ]


Heterogeneity: Chi2 = 3.58, df = 1 (P = 0.06); I2 =72%
Test for overall effect: Z = 1.84 (P = 0.066)
2 Role physical up to 12 months follow-up
Cripe 2010 104 15.14 (38.23) 100 11.25 (31.26) 76.8 % 3.89 [ -5.68, 13.46 ]

Tiwari 2005 55 29.09 (45.84) 55 10 (47.29) 23.2 % 19.09 [ 1.68, 36.50 ]

Subtotal (95% CI) 159 155 100.0 % 7.42 [ -0.97, 15.80 ]


Heterogeneity: Chi2 = 2.25, df = 1 (P = 0.13); I2 =56%
Test for overall effect: Z = 1.73 (P = 0.083)
3 Bodily pain up to 12 months follow-up
Cripe 2010 104 7.4 (28.33) 100 7.9 (24.28) 66.7 % -0.50 [ -7.73, 6.73 ]

Tiwari 2005 55 -7.27 (25.56) 55 5.27 (29.05) 33.3 % -12.54 [ -22.77, -2.31 ]

Subtotal (95% CI) 159 155 100.0 % -4.51 [ -10.42, 1.39 ]


Heterogeneity: Chi2 = 3.55, df = 1 (P = 0.06); I2 =72%
Test for overall effect: Z = 1.50 (P = 0.13)
4 General health up to 12 months follow-up
Cripe 2010 104 -5.3 (15.62) 100 -4.74 (14.67) 59.8 % -0.56 [ -4.72, 3.60 ]

Tiwari 2005 55 -7 (11.16) 55 -5.73 (15.62) 40.2 % -1.27 [ -6.34, 3.80 ]

Subtotal (95% CI) 159 155 100.0 % -0.85 [ -4.06, 2.37 ]


Heterogeneity: Chi2 = 0.05, df = 1 (P = 0.83); I2 =0.0%
Test for overall effect: Z = 0.52 (P = 0.61)
5 Vitality up to 12 months follow-up
Cripe 2010 104 0.19 (22.34) 100 3.65 (22.06) 47.0 % -3.46 [ -9.55, 2.63 ]

Tiwari 2005 55 -5.36 (14.78) 55 -5.82 (15.92) 53.0 % 0.46 [ -5.28, 6.20 ]

Subtotal (95% CI) 159 155 100.0 % -1.38 [ -5.56, 2.80 ]


Heterogeneity: Chi2 = 0.84, df = 1 (P = 0.36); I2 =0.0%
Test for overall effect: Z = 0.65 (P = 0.52)

-50 -25 0 25 50
Favours control Favours intervention
(Continued . . . )

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(. . . Continued)
Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
6 Social functioning up to 12 months follow-up
Cripe 2010 104 0.36 (34.94) 100 3.5 (37.06) 35.8 % -3.14 [ -13.03, 6.75 ]

Tiwari 2005 55 0.91 (20.11) 55 -2.27 (19.41) 64.2 % 3.18 [ -4.21, 10.57 ]

Subtotal (95% CI) 159 155 100.0 % 0.92 [ -5.00, 6.84 ]


Heterogeneity: Chi2 = 1.01, df = 1 (P = 0.32); I2 =1%
Test for overall effect: Z = 0.30 (P = 0.76)
7 Role emotional up to 12 months follow-up
Cripe 2010 104 6.41 (47.16) 100 4 (34.91) 72.7 % 2.41 [ -8.95, 13.77 ]

Tiwari 2005 55 21.82 (46.8) 55 -6.06 (52.15) 27.3 % 27.88 [ 9.36, 46.40 ]

Subtotal (95% CI) 159 155 100.0 % 9.37 [ -0.31, 19.05 ]


Heterogeneity: Chi2 = 5.28, df = 1 (P = 0.02); I2 =81%
Test for overall effect: Z = 1.90 (P = 0.058)
8 Mental health up to 12 months follow-up
Cripe 2010 104 -2.5 (20.95) 100 2.04 (19.61) 41.6 % -4.54 [ -10.11, 1.03 ]

Tiwari 2005 55 -0.51 (11.21) 55 -0.8 (13.78) 58.4 % 0.29 [ -4.40, 4.98 ]

Subtotal (95% CI) 159 155 100.0 % -1.72 [ -5.31, 1.87 ]


Heterogeneity: Chi2 = 1.69, df = 1 (P = 0.19); I2 =41%
Test for overall effect: Z = 0.94 (P = 0.35)
Test for subgroup differences: Chi2 = 13.89, df = 7 (P = 0.05), I2 =50%

-50 -25 0 25 50
Favours control Favours intervention

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Analysis 7.3. Comparison 7 Quality of life, Outcome 3 Intensive advocacy: 2 summary component subscales.

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

Comparison: 7 Quality of life

Outcome: 3 Intensive advocacy: 2 summary component subscales

Mean Mean
Study or subgroup Intervention Control Difference Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 Physical component up to 12 months follow-up


Taft 2011 71 52.4 (11.9) 32 47.5 (8) 4.90 [ 0.98, 8.82 ]

2 Mental component up to 12 months follow-up


Taft 2011 71 37.8 (11.2) 32 35.9 (11.7) 1.90 [ -2.92, 6.72 ]

-10 -5 0 5 10
Favours control Favours intervention

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Analysis 7.4. Comparison 7 Quality of life, Outcome 4 Intensive advocacy: overall.

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

Comparison: 7 Quality of life

Outcome: 4 Intensive advocacy: overall

Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 Up to 12 months follow-up
Sullivan 1992 135 5.08 (1.01) 130 4.87 (1.04) 87.8 % 0.21 [ -0.04, 0.46 ]

Sullivan 2002 45 4.8 (1.49) 33 4.4 (1.46) 12.2 % 0.40 [ -0.26, 1.06 ]

Subtotal (95% CI) 180 163 100.0 % 0.23 [ 0.00, 0.46 ]


Heterogeneity: Chi2 = 0.28, df = 1 (P = 0.60); I2 =0.0%
Test for overall effect: Z = 1.98 (P = 0.048)
2 12 to 24 months follow-up
Sullivan 1992 135 5.19 (1.09) 130 4.94 (1.15) 100.0 % 0.25 [ -0.02, 0.52 ]

Subtotal (95% CI) 135 130 100.0 % 0.25 [ -0.02, 0.52 ]


Heterogeneity: not applicable
Test for overall effect: Z = 1.81 (P = 0.070)
3 24 + months follow-up
Sullivan 1992 62 5.07 (1.01) 62 4.77 (1.1) 100.0 % 0.30 [ -0.07, 0.67 ]

Subtotal (95% CI) 62 62 100.0 % 0.30 [ -0.07, 0.67 ]


Heterogeneity: not applicable
Test for overall effect: Z = 1.58 (P = 0.11)
Test for subgroup differences: Chi2 = 0.09, df = 2 (P = 0.96), I2 =0.0%

-4 -2 0 2 4
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Analysis 7.5. Comparison 7 Quality of life, Outcome 5 Any advocacy: 2 summary component subscales.

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

Comparison: 7 Quality of life

Outcome: 5 Any advocacy: 2 summary component subscales

Std. Std.
Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 Physical component up to 12 months follow-up


Taft 2011 71 52.4 (11.9) 32 47.5 (8) 30.2 % 0.45 [ 0.03, 0.87 ]

Tiwari 2010 100 44.35 (7.64) 100 43.55 (7.3) 69.8 % 0.11 [ -0.17, 0.38 ]

Subtotal (95% CI) 171 132 100.0 % 0.21 [ -0.02, 0.44 ]


Heterogeneity: Chi2 = 1.76, df = 1 (P = 0.19); I2 =43%
Test for overall effect: Z = 1.77 (P = 0.076)
2 Mental component up to 12 months
Taft 2011 71 37.8 (11.2) 32 35.9 (11.7) 30.6 % 0.17 [ -0.25, 0.58 ]

Tiwari 2010 100 38.26 (8.56) 100 37.89 (8.08) 69.4 % 0.04 [ -0.23, 0.32 ]

Subtotal (95% CI) 171 132 100.0 % 0.08 [ -0.15, 0.31 ]


Heterogeneity: Chi2 = 0.23, df = 1 (P = 0.63); I2 =0.0%
Test for overall effect: Z = 0.69 (P = 0.49)

-1 -0.5 0 0.5 1
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Analysis 8.1. Comparison 8 Depression, Outcome 1 Brief advocacy (up to 12 months follow-up).

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

Comparison: 8 Depression

Outcome: 1 Brief advocacy (up to 12 months follow-up)

Std. Std.
Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Gillum 2009 19 16.2 (19.2) 20 17.3 (14.2) 16.4 % -0.06 [ -0.69, 0.56 ]

Tiwari 2010 100 16.1 (10.69) 100 18.25 (11.4) 83.6 % -0.19 [ -0.47, 0.08 ]

Total (95% CI) 119 120 100.0 % -0.17 [ -0.43, 0.08 ]


Heterogeneity: Chi2 = 0.14, df = 1 (P = 0.71); I2 =0.0%
Test for overall effect: Z = 1.33 (P = 0.18)
Test for subgroup differences: Not applicable

-1 -0.5 0 0.5 1
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Analysis 8.2. Comparison 8 Depression, Outcome 2 Brief advocacy (dichotomous outcome) (up to 12
months follow-up).

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

Comparison: 8 Depression

Outcome: 2 Brief advocacy (dichotomous outcome) (up to 12 months follow-up)

Study or subgroup Intervention Control Odds Ratio Weight Odds Ratio


n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Gillum 2009 7/19 10/20 22.7 % 0.58 [ 0.16, 2.10 ]

Tiwari 2005 9/55 25/55 77.3 % 0.23 [ 0.10, 0.57 ]

Total (95% CI) 74 75 100.0 % 0.31 [ 0.15, 0.65 ]


Total events: 16 (Intervention), 35 (Control)
Heterogeneity: Chi2 = 1.31, df = 1 (P = 0.25); I2 =24%
Test for overall effect: Z = 3.15 (P = 0.0016)
Test for subgroup differences: Not applicable

0.05 0.2 1 5 20
Favours intervention Favours control

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Analysis 8.3. Comparison 8 Depression, Outcome 3 Intensive advocacy.

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

Comparison: 8 Depression

Outcome: 3 Intensive advocacy

Std. Std.
Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 Up to 12 months follow-up
Sullivan 1992 135 1.97 (0.63) 130 1.98 (0.67) 62.0 % -0.02 [ -0.26, 0.23 ]

Sullivan 2002 45 2.09 (0.82) 33 2.35 (0.8) 17.6 % -0.32 [ -0.77, 0.13 ]

Taft 2011 71 9.2 (4.5) 32 11.2 (7) 20.4 % -0.37 [ -0.79, 0.05 ]

Subtotal (95% CI) 251 195 100.0 % -0.14 [ -0.33, 0.05 ]


Heterogeneity: Chi2 = 2.75, df = 2 (P = 0.25); I2 =27%
Test for overall effect: Z = 1.45 (P = 0.15)
2 12 to 24 months follow-up
Sullivan 1992 135 1.92 (0.69) 130 2 (0.65) 100.0 % -0.12 [ -0.36, 0.12 ]

Subtotal (95% CI) 135 130 100.0 % -0.12 [ -0.36, 0.12 ]


Heterogeneity: not applicable
Test for overall effect: Z = 0.97 (P = 0.33)
Test for subgroup differences: Chi2 = 0.02, df = 1 (P = 0.89), I2 =0.0%

-1 -0.5 0 0.5 1
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Analysis 8.4. Comparison 8 Depression, Outcome 4 Intensive advocacy (dichotomous outcome) (up to 12
months follow-up).

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

Comparison: 8 Depression

Outcome: 4 Intensive advocacy (dichotomous outcome) (up to 12 months follow-up)

Study or subgroup Intervention Control Odds Ratio Odds Ratio


n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Taft 2011 15/71 11/32 0.51 [ 0.20, 1.29 ]

0.2 0.5 1 2 5
Favours intervention Favours control

Analysis 8.5. Comparison 8 Depression, Outcome 5 Any advocacy (up to 12 months follow-up).

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

Comparison: 8 Depression

Outcome: 5 Any advocacy (up to 12 months follow-up)

Std. Std.
Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Gillum 2009 19 16.2 (19.2) 20 17.3 (14.2) 5.9 % -0.06 [ -0.69, 0.56 ]

Sullivan 1992 135 1.97 (0.63) 130 1.98 (0.67) 39.8 % -0.02 [ -0.26, 0.23 ]

Sullivan 2002 45 2.09 (0.82) 33 2.35 (0.8) 11.3 % -0.32 [ -0.77, 0.13 ]

Taft 2011 71 9.2 (4.5) 32 11.2 (7) 13.1 % -0.37 [ -0.79, 0.05 ]

Tiwari 2010 100 16.1 (10.69) 100 18.25 (11.4) 29.9 % -0.19 [ -0.47, 0.08 ]

Total (95% CI) 370 315 100.0 % -0.15 [ -0.30, 0.00 ]


Heterogeneity: Chi2 = 2.93, df = 4 (P = 0.57); I2 =0.0%
Test for overall effect: Z = 1.96 (P = 0.050)
Test for subgroup differences: Not applicable

-1 -0.5 0 0.5 1
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Analysis 8.6. Comparison 8 Depression, Outcome 6 Any advocacy (dichotomous outcome) (up to 12
months follow-up).

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

Comparison: 8 Depression

Outcome: 6 Any advocacy (dichotomous outcome) (up to 12 months follow-up)

Study or subgroup Intervention Control Odds Ratio Weight Odds Ratio


n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Gillum 2009 7/19 10/20 15.8 % 0.58 [ 0.16, 2.10 ]

Taft 2011 15/71 11/32 30.7 % 0.51 [ 0.20, 1.29 ]

Tiwari 2005 9/55 25/55 53.6 % 0.23 [ 0.10, 0.57 ]

Total (95% CI) 145 107 100.0 % 0.37 [ 0.21, 0.66 ]


Total events: 31 (Intervention), 46 (Control)
Heterogeneity: Chi2 = 1.95, df = 2 (P = 0.38); I2 =0.0%
Test for overall effect: Z = 3.41 (P = 0.00064)
Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10


Favours intervention Favours control

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intimate partner abuse (Review)
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Analysis 9.1. Comparison 9 Anxiety, Outcome 1 Brief advocacy (up to 12 months follow-up).

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

Comparison: 9 Anxiety

Outcome: 1 Brief advocacy (up to 12 months follow-up)

Mean Mean
Study or subgroup Intervention Control Difference Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Hyman 2001 31 0.72 (0.69) 22 1.28 (1.12) -0.56 [ -1.09, -0.03 ]

-2 -1 0 1 2
Favours intervention Favours control

Analysis 9.2. Comparison 9 Anxiety, Outcome 2 Intensive advocacy.

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

Comparison: 9 Anxiety

Outcome: 2 Intensive advocacy

Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 Up to 12 months follow-up
Sullivan 1992 135 1.03 (0.88) 130 1.16 (0.95) 100.0 % -0.13 [ -0.35, 0.09 ]

Subtotal (95% CI) 135 130 100.0 % -0.13 [ -0.35, 0.09 ]


Heterogeneity: not applicable
Test for overall effect: Z = 1.15 (P = 0.25)
2 12 to 24 months follow-up
Sullivan 1992 135 1.01 (0.88) 130 1.02 (0.86) 100.0 % -0.01 [ -0.22, 0.20 ]

Subtotal (95% CI) 135 130 100.0 % -0.01 [ -0.22, 0.20 ]


Heterogeneity: not applicable
Test for overall effect: Z = 0.09 (P = 0.93)
3 24 + months follow-up

-0.5 -0.25 0 0.25 0.5


Favours intervention Favours control
(Continued . . . )

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Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(. . . Continued)
Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Sullivan 1992 62 1.01 (0.81) 62 1.12 (0.81) 100.0 % -0.11 [ -0.40, 0.18 ]

Subtotal (95% CI) 62 62 100.0 % -0.11 [ -0.40, 0.18 ]


Heterogeneity: not applicable
Test for overall effect: Z = 0.76 (P = 0.45)
Test for subgroup differences: Chi2 = 0.67, df = 2 (P = 0.72), I2 =0.0%

-0.5 -0.25 0 0.25 0.5


Favours intervention Favours control

Analysis 9.3. Comparison 9 Anxiety, Outcome 3 Intensive advocacy (mean change) (up to 12 months
follow-up).

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

Comparison: 9 Anxiety

Outcome: 3 Intensive advocacy (mean change) (up to 12 months follow-up)

Mean Mean
Study or subgroup Intervention Control Difference Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Constantino 2005 13 -43.77 (43.28) 11 -8.36 (55.93) -35.41 [ -75.98, 5.16 ]

-100 -50 0 50 100


Favours intervention Favours control

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Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 9.4. Comparison 9 Anxiety, Outcome 4 Any advocacy (up to 12 months follow-up).

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

Comparison: 9 Anxiety

Outcome: 4 Any advocacy (up to 12 months follow-up)

Std. Std.
Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Hyman 2001 31 0.72 (0.69) 22 1.28 (1.12) 15.6 % -0.62 [ -1.18, -0.06 ]

Sullivan 1992 135 1.03 (0.88) 130 1.16 (0.95) 84.4 % -0.14 [ -0.38, 0.10 ]

Total (95% CI) 166 152 100.0 % -0.22 [ -0.44, 0.01 ]


Heterogeneity: Chi2 = 2.35, df = 1 (P = 0.13); I2 =57%
Test for overall effect: Z = 1.91 (P = 0.056)
Test for subgroup differences: Not applicable

-4 -2 0 2 4
Favours intervention Favours control

Analysis 10.1. Comparison 10 Chronic pain, Outcome 1 Brief advocacy (up to 12 months follow-up).

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

Comparison: 10 Chronic pain

Outcome: 1 Brief advocacy (up to 12 months follow-up)

Mean Mean
Study or subgroup Intervention Control Difference Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Gillum 2009 19 29.8 (26.5) 20 40.3 (25.3) -10.50 [ -26.78, 5.78 ]

-20 -10 0 10 20
Favours intervention Favours control

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intimate partner abuse (Review)
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Analysis 11.1. Comparison 11 Chronic fatigue, Outcome 1 Brief advocacy (up to 12 months follow-up).

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

Comparison: 11 Chronic fatigue

Outcome: 1 Brief advocacy (up to 12 months follow-up)

Mean Mean
Study or subgroup Intervention Control Difference Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Gillum 2009 19 29.8 (26.6) 20 40.3 (25.3) -10.50 [ -26.81, 5.81 ]

-50 -25 0 25 50
Favours intervention Favours control

Analysis 12.1. Comparison 12 Low birth weight, Outcome 1 Brief advocacy (dichotomous outcome).

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

Comparison: 12 Low birth weight

Outcome: 1 Brief advocacy (dichotomous outcome)

Study or subgroup Intervention Control Odds Ratio Odds Ratio


n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

1 Low birth weight (< 2500 g)


Kiely 2010 17/150 24/156 0.70 [ 0.36, 1.37 ]

2 Very low birth weight (< 1500 g)


Kiely 2010 1/150 6/156 0.17 [ 0.02, 1.41 ]

0.02 0.1 1 10 50
Favours intervention Favours control

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intimate partner abuse (Review)
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Analysis 13.1. Comparison 13 Birth weight (grams), Outcome 1 Brief advocacy.

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

Comparison: 13 Birth weight (grams)

Outcome: 1 Brief advocacy

Mean Mean
Study or subgroup Intervention Control Difference Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Kiely 2010 150 3139 (593) 156 3098 (717) 41.00 [ -106.19, 188.19 ]

-200 -100 0 100 200


Favours control Favours intervention

Analysis 14.1. Comparison 14 Pre-term birth, Outcome 1 Brief advocacy (dichotomous outcome).

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

Comparison: 14 Pre-term birth

Outcome: 1 Brief advocacy (dichotomous outcome)

Study or subgroup Intervention Control Odds Ratio Odds Ratio


n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

1 Pre-term birth (37 weeks gestation)


Kiely 2010 18/150 27/156 0.65 [ 0.34, 1.24 ]

2 Very pre-term birth (< 33 weeks gestation)


Kiely 2010 2/150 9/156 0.22 [ 0.05, 1.04 ]

0.05 0.2 1 5 20
Favours intervention Favours control

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intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 15.1. Comparison 15 Gestational age (weeks) at delivery, Outcome 1 Brief advocacy.

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

Comparison: 15 Gestational age (weeks) at delivery

Outcome: 1 Brief advocacy

Mean Mean
Study or subgroup Intervention Control Difference Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Kiely 2010 150 38.2 (3.3) 156 36.9 (5.9) 1.30 [ 0.23, 2.37 ]

-2 -1 0 1 2
Favours control Favours intervention

Analysis 16.1. Comparison 16 Post-traumatic stress, Outcome 1 Brief advocacy (up to 12 months follow-up).

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

Comparison: 16 Post-traumatic stress

Outcome: 1 Brief advocacy (up to 12 months follow-up)

Std. Std.
Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Gillum 2009 19 36.5 (44.7) 20 32.6 (31.7) 43.7 % 0.10 [ -0.53, 0.73 ]

Hyman 2001 31 29.23 (24.14) 22 41.5 (30.98) 56.3 % -0.44 [ -1.00, 0.11 ]

Total (95% CI) 50 42 100.0 % -0.21 [ -0.62, 0.21 ]


Heterogeneity: Chi2 = 1.62, df = 1 (P = 0.20); I2 =38%
Test for overall effect: Z = 0.98 (P = 0.33)
Test for subgroup differences: Not applicable

-2 -1 0 1 2
Favours intervention Favours control

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intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 17.1. Comparison 17 Perception of stress, Outcome 1 Brief advocacy (up to 12 months follow-up).

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

Comparison: 17 Perception of stress

Outcome: 1 Brief advocacy (up to 12 months follow-up)

Mean Mean
Study or subgroup Intervention Control Difference Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Hyman 2001 31 0.72 (0.69) 22 1.28 (1.12) -0.56 [ -1.09, -0.03 ]

-2 -1 0 1 2
Favours intervention Favours control

Analysis 18.1. Comparison 18 Self efficacy, Outcome 1 Intensive advocacy.

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

Comparison: 18 Self efficacy

Outcome: 1 Intensive advocacy

Mean Mean
Study or subgroup Intervention Control Difference Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 Up to 12 months follow-up
Sullivan 1992 135 5.87 (1.07) 130 5.79 (1.16) 0.08 [ -0.19, 0.35 ]

2 12 to 24 months follow-up
Sullivan 1992 135 5.97 (1.02) 130 5.81 (1.1) 0.16 [ -0.10, 0.42 ]

3 24 + months follow-up
Sullivan 1992 62 5.91 (0.95) 62 5.77 (1.11) 0.14 [ -0.22, 0.50 ]

-1 -0.5 0 0.5 1
Favours control Favours intervention

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intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 19.1. Comparison 19 Self esteem, Outcome 1 Intensive advocacy (up to 12 months follow-up).

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

Comparison: 19 Self esteem

Outcome: 1 Intensive advocacy (up to 12 months follow-up)

Mean Mean
Study or subgroup Intervention Control Difference Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Sullivan 2002 45 3.22 (0.66) 33 2.96 (0.65) 0.26 [ -0.03, 0.55 ]

-1 -0.5 0 0.5 1
Favours control Favours intervention

Analysis 20.1. Comparison 20 Perceived social support, Outcome 1 Brief advocacy (up to 12 months follow-
up).

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

Comparison: 20 Perceived social support

Outcome: 1 Brief advocacy (up to 12 months follow-up)

Mean Mean
Study or subgroup Intervention Control Difference Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Tiwari 2010 100 21.09 (7.02) 100 19.49 (7.2) 1.60 [ -0.37, 3.57 ]

-4 -2 0 2 4
Favours control Favours intervention

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intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 20.2. Comparison 20 Perceived social support, Outcome 2 Intensive advocacy.

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

Comparison: 20 Perceived social support

Outcome: 2 Intensive advocacy

Std. Std.
Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 Up to 12 months follow-up
Sullivan 1992 135 5.32 (1.12) 130 5.19 (1.12) 61.8 % 0.12 [ -0.13, 0.36 ]

Sullivan 2002 45 4.76 (1.29) 33 4.88 (1.27) 17.8 % -0.09 [ -0.54, 0.36 ]

Taft 2011 71 3.19 (1.03) 32 3.44 (0.93) 20.5 % -0.25 [ -0.67, 0.17 ]

Subtotal (95% CI) 251 195 100.0 % 0.00 [ -0.19, 0.19 ]


Heterogeneity: Chi2 = 2.40, df = 2 (P = 0.30); I2 =16%
Test for overall effect: Z = 0.04 (P = 0.96)
2 12 to 24 months follow-up
Sullivan 1992 135 5.46 (1.02) 130 5.33 (1.06) 100.0 % 0.12 [ -0.12, 0.37 ]

Subtotal (95% CI) 135 130 100.0 % 0.12 [ -0.12, 0.37 ]


Heterogeneity: not applicable
Test for overall effect: Z = 1.01 (P = 0.31)
3 24 + months follow-up
Sullivan 1992 62 5.48 (0.97) 62 5.09 (1.04) 100.0 % 0.39 [ 0.03, 0.74 ]

Subtotal (95% CI) 62 62 100.0 % 0.39 [ 0.03, 0.74 ]


Heterogeneity: not applicable
Test for overall effect: Z = 2.13 (P = 0.034)
Test for subgroup differences: Chi2 = 3.50, df = 2 (P = 0.17), I2 =43%

-1 -0.5 0 0.5 1
Favours control Favours intervention

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intimate partner abuse (Review)
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Analysis 20.3. Comparison 20 Perceived social support, Outcome 3 Intensive advocacy (mean change).

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

Comparison: 20 Perceived social support

Outcome: 3 Intensive advocacy (mean change)

Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 Overall support up to 12 months follow-up


Constantino 2005 13 10.46 (8.31) 11 0.27 (0.24) 100.0 % 10.19 [ 5.67, 14.71 ]

Subtotal (95% CI) 13 11 100.0 % 10.19 [ 5.67, 14.71 ]


Heterogeneity: not applicable
Test for overall effect: Z = 4.42 (P < 0.00001)
2 Tangible support up to 12 months follow-up
Constantino 2005 13 2.92 (2.25) 11 0.73 (0.54) 100.0 % 2.19 [ 0.93, 3.45 ]

Subtotal (95% CI) 13 11 100.0 % 2.19 [ 0.93, 3.45 ]


Heterogeneity: not applicable
Test for overall effect: Z = 3.40 (P = 0.00068)
3 Appraisal support up to 12 months follow-up
Constantino 2005 13 1.31 (0.9) 11 0.64 (0.34) 100.0 % 0.67 [ 0.14, 1.20 ]

Subtotal (95% CI) 13 11 100.0 % 0.67 [ 0.14, 1.20 ]


Heterogeneity: not applicable
Test for overall effect: Z = 2.48 (P = 0.013)
4 Self esteem support up to 12 months follow-up
Constantino 2005 13 2.23 (1.16) 11 1.09 (0.55) 100.0 % 1.14 [ 0.43, 1.85 ]

Subtotal (95% CI) 13 11 100.0 % 1.14 [ 0.43, 1.85 ]


Heterogeneity: not applicable
Test for overall effect: Z = 3.15 (P = 0.0016)
5 Belonging support up to 12 months follow-up
Constantino 2005 13 3 (4.16) 11 -1.18 (3.34) 100.0 % 4.18 [ 1.18, 7.18 ]

Subtotal (95% CI) 13 11 100.0 % 4.18 [ 1.18, 7.18 ]


Heterogeneity: not applicable
Test for overall effect: Z = 2.73 (P = 0.0063)

-10 -5 0 5 10
Favours control Favours intervention

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intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 20.4. Comparison 20 Perceived social support, Outcome 4 Any advocacy (up to 12 months follow-
up).

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

Comparison: 20 Perceived social support

Outcome: 4 Any advocacy (up to 12 months follow-up)

Std. Std.
Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Sullivan 1992 135 5.32 (1.12) 130 5.19 (1.12) 42.2 % 0.12 [ -0.13, 0.36 ]

Sullivan 2002 45 4.76 (1.29) 33 4.88 (1.27) 12.1 % -0.09 [ -0.54, 0.36 ]

Taft 2011 71 3.19 (1.03) 32 3.44 (0.93) 14.0 % -0.25 [ -0.67, 0.17 ]

Tiwari 2010 100 21.09 (7.02) 100 19.49 (7.2) 31.7 % 0.22 [ -0.05, 0.50 ]

Total (95% CI) 351 295 100.0 % 0.07 [ -0.08, 0.23 ]


Heterogeneity: Chi2 = 4.04, df = 3 (P = 0.26); I2 =26%
Test for overall effect: Z = 0.93 (P = 0.35)
Test for subgroup differences: Not applicable

-1 -0.5 0 0.5 1
Favours control Favours intervention

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intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 21.1. Comparison 21 Independence from abuser, Outcome 1 Intensive advocacy (dichotomous
outcome).

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

Comparison: 21 Independence from abuser

Outcome: 1 Intensive advocacy (dichotomous outcome)

Study or subgroup Intervention Control Odds Ratio Weight Odds Ratio


n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

1 Up to 12 months follow-up
Sullivan 1991 21/25 13/16 9.0 % 1.21 [ 0.23, 6.30 ]

Sullivan 1992 46/132 39/128 91.0 % 1.22 [ 0.73, 2.05 ]

Subtotal (95% CI) 157 144 100.0 % 1.22 [ 0.74, 2.00 ]


Total events: 67 (Intervention), 52 (Control)
Heterogeneity: Chi2 = 0.00, df = 1 (P = 0.99); I2 =0.0%
Test for overall effect: Z = 0.79 (P = 0.43)
2 12 to 24 months follow-up
Sullivan 1992 61/132 52/129 100.0 % 1.27 [ 0.78, 2.08 ]

Subtotal (95% CI) 132 129 100.0 % 1.27 [ 0.78, 2.08 ]


Total events: 61 (Intervention), 52 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.96 (P = 0.34)
3 24 + months follow-up
Sullivan 1992 30/60 30/59 100.0 % 0.97 [ 0.47, 1.98 ]

Subtotal (95% CI) 60 59 100.0 % 0.97 [ 0.47, 1.98 ]


Total events: 30 (Intervention), 30 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 0.09 (P = 0.93)

0.1 0.2 0.5 1 2 5 10


Favours control Favours intervention

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Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 21.2. Comparison 21 Independence from abuser, Outcome 2 Intensive advocacy: missing
reassigned (up to 12 months follow-up) (dichotomous outcome).

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

Comparison: 21 Independence from abuser

Outcome: 2 Intensive advocacy: missing reassigned (up to 12 months follow-up) (dichotomous outcome)

Study or subgroup Intervention Control Odds Ratio Weight Odds Ratio


n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

1 Missing intervention group independent, control group not independent


Sullivan 1991 26/30 13/16 8.5 % 1.50 [ 0.29, 7.72 ]

Sullivan 1992 54/143 39/141 91.5 % 1.59 [ 0.96, 2.62 ]

Subtotal (95% CI) 173 157 100.0 % 1.58 [ 0.98, 2.55 ]


Total events: 80 (Intervention), 52 (Control)
Heterogeneity: Chi2 = 0.00, df = 1 (P = 0.95); I2 =0.0%
Test for overall effect: Z = 1.87 (P = 0.061)
2 Missing intervention group and control group all independent
Sullivan 1991 26/30 13/16 6.7 % 1.50 [ 0.29, 7.72 ]

Sullivan 1992 54/143 50/141 93.3 % 1.10 [ 0.68, 1.79 ]

Subtotal (95% CI) 173 157 100.0 % 1.13 [ 0.71, 1.80 ]


Total events: 80 (Intervention), 63 (Control)
Heterogeneity: Chi2 = 0.12, df = 1 (P = 0.73); I2 =0.0%
Test for overall effect: Z = 0.52 (P = 0.60)
3 Missing intervention group not independent, control group independent
Sullivan 1991 21/30 13/16 13.0 % 0.54 [ 0.12, 2.36 ]

Sullivan 1992 46/143 50/141 87.0 % 0.86 [ 0.53, 1.41 ]

Subtotal (95% CI) 173 157 100.0 % 0.82 [ 0.52, 1.31 ]


Total events: 67 (Intervention), 63 (Control)
Heterogeneity: Chi2 = 0.35, df = 1 (P = 0.55); I2 =0.0%
Test for overall effect: Z = 0.83 (P = 0.41)
4 Missing intervention group and control group all not independent
Sullivan 1991 21/30 13/16 16.0 % 0.54 [ 0.12, 2.36 ]

Sullivan 1992 46/143 39/141 84.0 % 1.24 [ 0.75, 2.06 ]

Subtotal (95% CI) 173 157 100.0 % 1.13 [ 0.70, 1.82 ]


Total events: 67 (Intervention), 52 (Control)
Heterogeneity: Chi2 = 1.09, df = 1 (P = 0.30); I2 =9%
Test for overall effect: Z = 0.49 (P = 0.62)

0.1 0.2 0.5 1 2 5 10


Favours control Favours intervention

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Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 22.1. Comparison 22 Emotional attachment to abuser, Outcome 1 Intensive advocacy.

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

Comparison: 22 Emotional attachment to abuser

Outcome: 1 Intensive advocacy

Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 Up to 12 months follow-up
Sullivan 1992 135 1.8 (0.26) 130 1.82 (0.23) 100.0 % -0.02 [ -0.08, 0.04 ]

Subtotal (95% CI) 135 130 100.0 % -0.02 [ -0.08, 0.04 ]


Heterogeneity: not applicable
Test for overall effect: Z = 0.66 (P = 0.51)
2 12 to 24 months follow-up
Sullivan 1992 135 1.86 (0.23) 130 1.86 (0.21) 100.0 % 0.0 [ -0.05, 0.05 ]

Subtotal (95% CI) 135 130 100.0 % 0.0 [ -0.05, 0.05 ]


Heterogeneity: not applicable
Test for overall effect: Z = 0.0 (P = 1.0)
3 24 + months follow-up
Sullivan 1992 62 1.85 (0.22) 62 1.92 (0.17) 100.0 % -0.07 [ -0.14, 0.00 ]

Subtotal (95% CI) 62 62 100.0 % -0.07 [ -0.14, 0.00 ]


Heterogeneity: not applicable
Test for overall effect: Z = 1.98 (P = 0.047)

-0.2 -0.1 0 0.1 0.2


Favours intervention Favours control

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Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 23.1. Comparison 23 Use of safety behaviours, Outcome 1 Brief advocacy.

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

Comparison: 23 Use of safety behaviours

Outcome: 1 Brief advocacy

Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 Up to 12 months follow-up
Gillum 2009 19 13.2 (2) 20 8.7 (3.3) 7.6 % 4.50 [ 2.80, 6.20 ]

McFarlane 2006 161 10 (2.5) 158 9.7 (2.5) 73.5 % 0.30 [ -0.25, 0.85 ]

Tiwari 2010 100 7.8 (3.7) 100 3.4 (4.1) 18.9 % 4.40 [ 3.32, 5.48 ]

Subtotal (95% CI) 280 278 100.0 % 1.39 [ 0.92, 1.87 ]


Heterogeneity: Chi2 = 57.67, df = 2 (P<0.00001); I2 =97%
Test for overall effect: Z = 5.81 (P < 0.00001)
2 12 to 24 months follow-up
McFarlane 2006 161 10.4 (2.3) 158 10.3 (2.4) 100.0 % 0.10 [ -0.42, 0.62 ]

Subtotal (95% CI) 161 158 100.0 % 0.10 [ -0.42, 0.62 ]


Heterogeneity: not applicable
Test for overall effect: Z = 0.38 (P = 0.70)

-4 -2 0 2 4
Favours control Favours intervention

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Analysis 24.1. Comparison 24 Use of resources, Outcome 1 Brief advocacy.

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

Comparison: 24 Use of resources

Outcome: 1 Brief advocacy

Std. Std.
Mean Mean
Study or subgroup Intervention Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 Up to 12 months follow-up
Gillum 2009 19 4.1 (3.1) 20 4.5 (3.9) 10.9 % -0.11 [ -0.74, 0.52 ]

McFarlane 2006 161 1.4 (1.4) 158 1.1 (1.3) 89.1 % 0.22 [ 0.00, 0.44 ]

Subtotal (95% CI) 180 178 100.0 % 0.19 [ -0.02, 0.39 ]


Heterogeneity: Chi2 = 0.96, df = 1 (P = 0.33); I2 =0.0%
Test for overall effect: Z = 1.75 (P = 0.081)
2 12 to 24 months follow-up
McFarlane 2006 161 1 (1.3) 158 0.8 (1.3) 100.0 % 0.15 [ -0.07, 0.37 ]

Subtotal (95% CI) 161 158 100.0 % 0.15 [ -0.07, 0.37 ]


Heterogeneity: not applicable
Test for overall effect: Z = 1.37 (P = 0.17)

-1 -0.5 0 0.5 1
Favours control Favours intervention

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Analysis 25.1. Comparison 25 Difficulty obtaining resources, Outcome 1 Intensive advocacy.

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

Comparison: 25 Difficulty obtaining resources

Outcome: 1 Intensive advocacy

Mean Mean
Study or subgroup Favours intervention Control Difference Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Sullivan 1992 62 2.05 (0.59) 62 2.17 (0.6) -0.12 [ -0.33, 0.09 ]

Sullivan 1992 135 2.23 (0.64) 130 2.24 (0.58) -0.01 [ -0.16, 0.14 ]

Sullivan 1992 135 2.01 (0.63) 130 2.19 (0.66) -0.18 [ -0.34, -0.02 ]

-0.5 -0.25 0 0.25 0.5


Favours intervention Favours control

ADDITIONAL TABLES
Table 1. Additional methods for use in future updates of this review

Issue Method

Assessment of reporting bias We planned to draw funnel plots to investigate possible relationships
between effect size and study precision, closely related to sample size
(Egger 1997). For meaningful funnel plots, a large number of trials with a
spread of sample sizes are required (Glasziou 2001; Hayashino 2005). We
planned to draw funnel plots if there were at least 7 trials with appropriate
data

Subgroup analyses and investigation of heterogeneity We plan to perform subgroup analyses for the following.
1. Single component interventions versus multi-component
interventions.
2. Interventions set in health service settings versus non-healthcare
settings.
Theoretical justification for subgroup analyses.
1. Domestic violence activists and service providers argue that the
effectiveness of advocacy is enhanced by integration of advocacy services
into a co-ordinated community response, including criminal justice
agencies, refuges/shelters, welfare support, and health services (Feder
2006a). This strategy, based on the Duluth model, is a network of
agreements, processes and applied principles created by the local shelter
movement, criminal justice agencies, healthcare, and human service
programmes (Clapp 2000). The proposed subgroup analysis will test

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Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Table 1. Additional methods for use in future updates of this review (Continued)

whether the (potential) effectiveness of advocacy is enhanced (or


diminished) by other interventions in the context of a co-ordinated
community response. It is theoretically plausible that even in the
absence of a fully co-ordinated community response, an additional
intervention combined with advocacy will have a synergistic effect;
therefore we will include studies that test a combined intervention, as
long as the control group is also exposed to the additional intervention.
2. If domestic violence advocacy is an effective intervention overall,
policy makers and service commissioners need to know if this effect is
moderated by the setting in which it is delivered. For example, if a
healthcare setting enhanced the effect, then this would be an
appropriate context for commissioning advocacy.

Sensitivity analyses To assess the robustness of conclusions to quality of data and approaches
to analysis, we will perform sensitivity analyses, including the following
1. The effects of risk of bias.
2. Differential dropout.
3. Intention-to-treat.
4. Duration of follow-up.

APPENDICES

Appendix 1. Search strategies from 2008 to 2015


In 2014, the searches were run by Margaret Anderson (Trials Search Co-ordinator CDPLPG), Jean Ramsay and Carol Rivas. The 2015
searches were run by Margaret Anderson.

Cochrane Central Database of Controlled Trials (CENTRAL, part of The Cochrane Library)
2011, Issue 3; searched 4 October 2011. Limited by publication year [45 records]
2013, Issue 2; searched 7 March 2013. Limited by publication year [17 records]
2014, Issue 1; searched 27 March 2014. Limited by publication year [6 records]
2015, Issue 4; searched 23 April 2015. Limited by publication year [6 records]
#1(battered wom*n)
#2MeSH descriptor: [Battered Women] explode all trees
#3MeSH descriptor: [Domestic Violence] this term only
#4MeSH descriptor: [Spouse Abuse] this term only
#5abuse near/3 (woman or women)
#6abuse* near/3 partner*
#7abuse* near/3 spouse*
#8wife near/3 batter* or wives near/3 batter*
#9wife* near/3 abuse* or wives near/3 abuse*
#10violen* near/3 partner* or violen* near/3 spous*
#11violen* near/3 date or violen* near/3 dating
#12#1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11
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#13child abuse
#14MeSH descriptor: [Child Abuse] this term only
#15MeSH descriptor: [Child Abuse, Sexual] this term only
#16#13 or #14 or #15
#17#12 not #16
#18wom*n or female*
#19MeSH descriptor: [Women] this term only
#20adolescen* or teen*
#21MeSH descriptor: [Adolescent] this term only
#22#18 or #19 or #20 or #21
#23advocacy
#24MeSH descriptor: [Patient Advocacy] this term only
#25MeSH descriptor: [Consumer Advocacy] explode all trees
#26counsel*
#27MeSH descriptor: [Counseling] explode all trees
#28social work
#29MeSH descriptor: [Social Work] explode all trees
#30mentor*
#31MeSH descriptor: [Mentors] this term only
#32crisis intervention
#33MeSH descriptor: [Crisis Intervention] this term only
#34risk assessment
#35MeSH descriptor: [Risk Assessment] this term only
#36MeSH descriptor: [Social Welfare] explode all trees
#37social welfare
#38social support
#39MeSH descriptor: [Social Support] this term only
#40help seeking
#41information giving
#42give near/3 information
#43advice giving
#44give near/3 advice or giving near/3 advice
#45patient education
#46MeSH descriptor: [Patient Education as Topic] this term only
#47MeSH descriptor: [Health Education] explode all trees
#48safety
#49MeSH descriptor: [Safety] explode all trees
#50women’s health
#51MeSH descriptor: [Women’s Health] explode all trees
#52#23 or #24 or #25 or #26 or #27 or #28 or #29 or #30 or #31 or #32 or #33 or #34 or #35 or #36 or #37 or #38 or #39 or #40 or
#41 or #42 or #43 or #44 or #45 or #46 or #47 or #48 or #49 or #50 or #51
#53#17 and #22 and #52
#54#53 from 2008 to 2011 (Limits applied October 2011)
#55#53 from 2011 to 2013 (Limits applied March 2013)
#56#53 from 2013 to 2014 (Limits applied March 2014)
#57#53 from 2014 to 2015 (Limits applied April 2015)

Ovid MEDLINE
1948 to September Week 3 searched 4 October 2011. Limited by date added [838 records]
1946 to February Week 4 2013 searched 7 March 2013. Limited by date added [354 records]
1946 to March Week 3 2014 searched 27 March 2014. Limited by date added [241 records]
1946 to April Week 3 2015 searched 23 April 2015. Limited by date added [74 records]
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1 Battered Women/
2 Domestic Violence/
3 Spouse abuse/
4 battered women.tw.
5 (abus$ adj3 partner$).tw.
6 (abus$ adj3 wom#n$).tw.
7 (abus$ adj3 spous$).tw.
8 ((wife or wives) adj3 batter$).tw.
9 ((wife or wives) adj3 abuse$).tw.
10 (violen$ adj3 partner$).tw.
11 (violen$ adj3 spous$).tw.
12 (violen$ adj3 (date or dating)).tw.
13 or/1-12
14 exp child abuse/
15 child$ abus$.tw.
16 (child adj3 abus$ adj3 sex$).tw.
17 or/14-16
18 13 not 17
19 Women/
20 Females/
21 (woman or women or female$).tw.
22 (adolescen$ or teen$).tw.
23 Adolescent/
24 or/19-23
25 Advocacy.tw.
26 exp Patient Advocacy/
27 exp Consumer Advocacy/
28 mentor$.tw.
29 exp Mentors/
30 exp Crisis Intervention/
31 Crisis Intervention.tw.
32 exp Patient Advocacy/
33 exp Consumer Advocacy/
34 exp Counseling/
35 counsel$.tw.
36 Social Work/
37 social work$.tw.
38 exp Risk Assessment/
39 risk assessment.tw.
40 exp Social Welfare/
41 social welfare.tw.
42 Social Support/
43 social support.tw.
44 help seeking.tw.
45 information giving.tw.
46 giving information.tw.
47 (giv$ adj3 information).tw.
48 advice giving.tw.
49 ((give or giving) adj3 advice).tw.
50 Patient Education as Topic/
51 exp Health Education/
52 patient educat$.tw.
53 health educat$.tw.
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54 exp Safety/
55 safety.tw.
56 womens health.tw.
57 Women’s Health/
58 or/25-57
59 18 and 24 and 58
60 limit 59 to ed=20080801-20111003 (Limits applied October 2011)
61 limit 59 to ed=20111001-20130307 (Limits applied March 2013)
62 limit 59 to ed=20130301-20140327 (Limits applied March 2014)
63 limit 59 to ed=20140301-20150423 (Limits applied April 2015)

EMBASE (Ovid)
1980 to 2011 Week 39 searched 3 October 2011. Limited by publication year [777 records]
1980 to 2013 Week 09 searched 7 March 2013. Limited by publication year [485 records]
1980 to 2014 Week 12 searched 27 March 2014. Limited by date added [431 records]
1980 to 2015 Week 17 searched 23 April 2015. Limited by date added [309 records]
1 battered women.tw.
2 Battered Women/
3 domestic violence/ or partner violence/ or family violence/ or battering/
4 (abuse adj3 (woman or women)).tw.
5 (abuse$ adj3 partner$).tw.
6 (abuse$ adj3 spouse$).tw.
7 ((wife or wives) adj3 batter$).tw.
8 ((wife or wives) adj3 abuse$).tw.
9 (violen$ adj3 partner$).tw.
10 (violen$ adj3 spous$).tw.
11 (violen$ adj3 (date or dating)).tw.
12 or/1-11
13 child abuse.tw.
14 child abuse/ or child abuse, sexual/
15 12 not (13 or 14)
16 (woman or women or female$).tw.
17 Women/
18 Female/
19 (adolescen$ or teen$).tw.
20 Adolescent/
21 or/16-20
22 advocacy.tw.
23 exp Patient Advocacy/
24 exp Consumer Advocacy/
25 counsel$.tw.
26 exp Patient Counseling/
27 social work.tw.
28 exp Social Work/
29 mentor$.tw.
31 crisis intervention.tw.
32 exp Crisis Intervention/
33 risk assessment.tw.
34 exp Risk Assessment/
35 exp Social Welfare/
36 social welfare.tw.
37 social support.tw.
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38 exp social support/
39 help seeking.tw.
40 information giving.tw.
41 (give adj3 information).tw.
42 advice giving.tw. (127)
43 ((give or giving) adj3 advice).tw.
44 patient education.tw.
45 exp Patient Education/
46 exp Health Education/
47 safety.tw.
48 exp Safety/
49 patient safety/
50 Womens health.tw.
51 or/22-50
52 15 and 21 and 51
53 limit 52 to yr=“2008 -Current” (Limits applied October 2011)
54 limit 52 to yr=“2011 - Current” (Limits applied March 2013)
55 limit 52 to em=201309-2014 (Limits applied March 2014)
56 limit 52 to em=201403-2015 (Limits applied April 2015)

PsycINFO (Ovid)
1806 to September Week 04 2011 searched 4 October 2011. Limited by publication year 2008 to current [512 records]
1806 to March Week 1 2013 searched 8 March 2013. Limited by date added 20111005 to 2013308 [213 records]
1806 to March Week 04 2014 searched 27 March 2014. Limited by date added 20130301 to 20140327 [157 records]
1806 to April Week 03 2015 searched 23 April 2015. Limited by date added 20140301 to 20150423 [201 records]
1 Battered Females/
2 Domestic Violence/
3 Partner Abuse/
4 Intimate Partner Violence/
5 battered women*.tw.
6 (abus$ adj5 partner$).tw.
7 (abus$ adj5 wom#n$).tw.
8 (abus$ adj5 spous$).tw.
9 ((wife or wives) adj5 batter$).tw.
10 ((wife or wives) adj5 abus$).tw.
11 (violen$ adj5 partner$).tw.
12 (violen$ adj5 spous$).tw.
13 (violen$ adj5 (date or dating)).tw.
14 or/1-13
15 exp child abuse/
16 child$ abus$.tw.
17 (child adj3 abus$ adj3 sex$).tw.
18 or/15-17
19 14 not 18
20 exp Human Females/
21 human females/ or mothers/ or wives/
22 (WOM#N or GIRL$ or FEMALE$).tw.
23 (adolescen$ or teen$).tw.
24 adolescence 13 17 yrs.ag.
25 21 or 22 or 23 or 24
26 Advocacy/
27 Advocacy.tw.
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28 mentor/
29 mentor$.tw.
30 exp Crisis Intervention/
31 Crisis Intervention.tw.
32 exp Risk Assessment/
33 risk assessment.tw.
34 social casework/
35 social welfare$.tw.
36 social support/
37 social support.tw.
38 help seeking behavior/
39 help seeking.tw.
40 (giv$ adj3 (advice$ or information$)).tw.
41 patient education.tw.
42 client education/
43 health education/
44 exp safety/
45 safety$.tw.
46 womens health.tw.
47 or/26-46
48 19 and 25 and 47

CINAHL PLus (EBSCOhost)


1937 to current searched 3 October 2011. Limited by date added [975 records]
1937 to current searched 7 March 2013. Limited by date added [437 records]
1937 to current searched 28 March 2014. Limited by date added [367 records]
1937 to current searched 23 April 2015. Limited by date added [235 records]
S55 S49 and S54 (Limits applied March 2014)
S54 EM >=20130301
S53 S49 and S52 (Limits applied March 2013)
S52 EM >=20111005
S51 S49 and S50 (Limits applied October 2011)
S50 EM >=20080730
S49 S8 and S18 and S48
S48 S19 or S20 or S21 or S22 or S23 or S24 or S25 or S26 or S27 or S28 or
S29 or S30 or S31 or S32 or S33 or S34 or S35 or S36 or S37 or S38 or S39
or S40 or S41 or S42 or S43 or S44 or S45 or S46 or S47
S47 women* health service*
S46 (MH “Women’s Health Services”)
S45 (MH “Women’s Health”)
S44 social work*
S43 (MH “Social Work+”)
S42 (MH “Patient Safety+”) OR (MH “Safety+”)
S41 safety
S40 patient* education
S39 health education
S38 (MH “Health Education+”)
S37 (MH “Patient Education+”)
S36 (giv* information* ) or (give* advice*)
S35 help seek* or help seek*
S34 (MH “Help Seeking Behavior”)
S33 (MH “Social Networks”)
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S32 (MH “Support, Psychosocial”) OR (MH “Social Capital”)
S31 social welfare*
S30 (MH “Social Welfare”)
S29 risk assessment*
S28 crisis intervention*
S27 (MH “Risk Assessment”)
S26 (MH “Crisis Intervention+”)
S25 mentor*
S24 (MH “Mentorship”)
S23 S21 or S22
S22 counsel*
S21 (MH “Counseling”)
S20 advocacy
S19 (MH “Consumer Advocacy”) OR (MH “Patient Advocacy”)
S18 S13 or S14 or S15 or S16 or S17
S17 teen* or adolescen*
S16 AG adolescent
S15 (MH “Mothers”)
S14 (MH “Women”)
S13 woman* or women* or female*
S12 S8 NOT S11
S11 S9 or S10
S9 (MH “Child Abuse”) OR (MH “Child Abuse, Sexual”)
S8 S1 or S2 or S3 or S4 or S5 or S6 or S7
S7 (violen* N5 partner*) or (violen* N5 spous*) or (violen* N5 date)
S6 (wife* N5 batter*) or (wife* N5 abus*) or (wives* N5 batter*)
S5 (ABUS* N5 WOMEN*) or (ABUS* N5 woman*) OR (Abus* N5 PARTNER*) OR (ABUS*
N5 SPOUS*)
S4 battered women*
S3 (MH “Domestic Violence”)
S2 (MH “Intimate Partner Violence”)
S1 (MH “Battered Women”)

ASSIA (Cambridge Scientific Abstracts)


1987 to current. Searched 1 August 2013 and 14 April 2014. Not available in April 2015
((((KW=((abuse* within 3 (wom?n or partner* or spous* or wife or wives)) or (batter* within 3 (wom?n or partner* or spous* or wife
or wives)) or (violen* within 3 (wom?n or partner* or spous* or wife or wives))) orKW=((family violence) or (domestic violence) or
(dat* violence))) and not (KW=((child* within 3 abuse) or (child* within 3 sex* within 3 abuse) or (child* within 3 maltreatment)))))
and ((KW=((wom?n or female* or mother*) or (adolescen* or teen*)))) and ((KW=((advocacy or counsel* or mentor*) or (crisis within
3 (intervention or management)) or (risk within 3 assessment)) or KW=((social within 3 (support or welfare)) or (help within 3 seek*)
or(giv* within 3 (information or advice))) orKW=((safety) or (education within 3 (patient or health)))))

Social Sciences Citation Index (SSCI; Web of Science)


1970 to current searched 4 October 2011. Limited by publication year. 2008 to 2011 [924 records]
1970 to 6 March 2013 searched 8 March 2013. Limited by date. 5 October 2011 to 8 March 2013 [554 records]
1970 to 26 March 2014 searched 27 March 2014. Limited by publication year. 2013 to 2014 [253 records]
1970 to 23 April 2015 searched 23 April 2015. Limited by publication year. 2014 to 2015 [202 records]
# 6 #5 AND #4 AND #3
Databases=SSCI
Lemmatization=Off
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# 5 TS=(advoca*) or TS=(counsel*) or TS=(mentor*) or TS=(Risk SAME Assessment) or TS=(social welfare) or TS==(Social SAME-
Support) or TS=(help* SAME seek*) or TS=(giv* SAME advice) or TS=(Patient SAME Education) or TS=(safety)
Databases=SSCI
Lemmatization=Off
# 4 TS=(adolescen* or teen*) or TS=(mother*) or TS=(female*) or TS=(wom*n )
Databases=SSCI
Lemmatization=Off
# 3 #1 not #2
Databases=SSCI
Lemmatization=Off
# 2 TS=(child SAME abuse) or TS=(child* SAME abuse* SAME sexual*)
Databases=SSCI
Lemmatization=Off
# 1 TS=(batter* SAME wom*n) or TS=(batter* SAME spous*) or TS=(batter* SAME partner*) or TS=(batter* SAME wife) or TS=
(batter* wives) or TS=(abuse* SAME wom*n) or TS=(abuse* SAME spous*) or TS=(abuse* SAME partner*) or TS=(abuse* SAME
wife) or TS=(abuse* wives) or TS=(violen* SAME wom*n) or TS=(violen* SAME spous*) or TS=(violen* SAME partner*) or TS=
(violen* SAME wife) or TS=(violen* wives) or TS=(domestic violence) or TS=(dat* SAME violen*)
Databases=SSCI
Lemmatization=Off

International Bibliography of Social Sciences (IBSS; ProQuest)


1951 to current searched 4 October 2011. Limited by publication year 2008 to 2011 [26 records]*
1951 to current searched 7 March 2013. Limited by publication year 2008 to 2013 [259 records]*
1951 to current searched 28 March 2014. LImited by publication year 2013 to 2014 [35 records]
1951 to current searched 23 April 2015. LImited by publication year 2014 to 2015 [5 records]
((TI(crisis near/3 (intervention or management)) or TI(risk near/3 assessment) or TI(social near/3 (support or welfare)) or TI(help
near/3 seek*) or TI(giv* near/3 (information or advice))) OR (AB(crisis near/3 (intervention or management)) or AB (risk near/3
assessment) or AB(social near/3 (support or welfare)) or AB (help near/3 seek*) or AB (giv* near/3 (information or advice)))) AND
(((TI((wom*n or female* or mother*) or (adolescen* or teen*))) OR (AB((wom*n or female* or mother*) or (adolescen* or teen*))))
AND ((TI((family violence) or (domestic violence) or (dat* violence))) OR (AB((family violence) or (domestic violence) or (dat*
violence))) OR ((TI((violen* near/3 (wom*n or partner* or spous* or wife or wives)))) OR (AB((violen* near/3 (wom*n or partner* or
spous* or wife or wives)))) OR (AB((batter* near/3 (wom*n or partner* or spous* or wife or wives)))) OR (TI((batter* near/3 (wom*n
or partner* or spous* or wife or wives)))) OR ((TI((abuse* near/3 (wom*n or partner* or spous* or wife or wives)))) OR (AB((abuse*
near/3 (wom*n or partner* or spous* or wife or wives))))) OR (TI((abuse* near/3 (wom*n or partner* or spous* or wife or wives))))
OR (AB((abuse* near/3 (wom*n or partner* or spous* or wife or wives)))))) AND (TI((wom*n or female* or mother*) or (adolescen*
or teen*))) AND (AB((wom*n or female* or mother*) or (adolescen* or teen*))))
* The number of records found by the 2011 search seemed very small, so the search was repeated for years 2008 onwards in 2013.

British Nursing Index (BNI; ProQuest)


Searched 1 August 2013 (2008 to 1 August 2013) [244 records]
1.(BATTERED ADJ WOMEN).TI,AB.
2.DOMESTIC-VIOLENCE.DE.
3.(ABUS$ NEAR (WOM$ OR SPOUS$)).TI,AB.
4.(ABUS$ NEAR (PARTNER$ OR WIFE OR WIVES)).TI,AB.
5.(BATTER$ NEAR (PARTNER$ OR WIFE OR WIVES)).TI,AB.
6.(BATTER$ NEAR (WOM$ OR SPOUS$)).TI,AB.
7.(VIOLEN$ NEAR (PARTNER$ OR WIFE OR WIVES)).TI,AB.
8.(VIOLEN$ NEAR (WOM$ OR SPOUS$)).TI,AB.
9.(VIOLEN$3 NEAR DAT$3).TI,AB.
10.1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9
11.(CHILD ADJ ABUSE).TI,AB.
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12.CHILD-ABUSE-AND-NEGLECT.DE. OR CHILD-ABUSE-SEXUAL.DE.
13.10 NOT (11 OR 12)
Searched 14 April 2014. Limited by publication date: 1 August 2013 to 14 April 2014 [52 records]
((TI,AB(“battered women”) OR SU.EXACT(“Domestic Violence”) OR TI,AB((abus*) NEAR (wom* or spous*)) OR TI,AB((abus*)
NEAR (partner* OR wife OR wives)) OR TI,AB((batter*) NEAR (partner* OR wife or wives)) OR TI,AB((batter*) NEAR (wom*
OR spous*)) OR TI,AB((violen*) NEAR (partner* OR wife OR wives)) OR TI,AB((violen*) NEAR (wom* OR spous*)) OR
TI,AB((violen*) NEAR (dat*3)) OR TI,AB((batter*) NEAR (wom*))) NOT (TI,AB((child*) near (abus*)) OR SU.EXACT(“Child
Abuse ”) OR SU.EXACT(“Child Abuse and Neglect”))) AND pd(20130801-20140414)

Health Management Information Consortium (HMIC; Ovid)


1979 to July 2011 searched October 2011. Limited by publication year 2008 to 2011 [41 records]
1979 to January 2013 searched 7 March 2013. Limited by publication year 2011 to 2013 [23 records]
1979 to January 2014 searched 27 March 2014. Limited by publication year 2013 to 2014 [9 records]
1979 to January 2015 searched 23 April 2015. Limited by publication year 2014 to 2015 [1 record]
1 domestic violence/ or partner abuse/
2 ((violen$ adj3 dat$) or (violen$ adj3 domestic) or (violen$ adj3 family) or ((violen$ adj3 spous$) or (violen$ adj3 partner$) or
(violen$ adj3 wi$)) or ((abuse$ adj3 partner$) or (abuse$ adj3 wi$) or (violen$ adj3 wom$n)) or ((batter$ adj3 wi$) or (abuse$ adj3
wom$n) or (abuse$ adj3 spous$)) or ((batter$ adj3 wom#n) or (batter$ adj3 spous$) or (batter$ adj3 partner$))).mp. [mp=title, other
title, abstract, heading words]
3 1 or 2
4 Crisis intervention/
5 exp risk assessment/
6 counselling/
7 social welfare/
8 Social work/
9 Patient education/
10 Health education/
11 Mentoring/
12 Social support/
13 Safety/
14 exp Womens health/
15 advocacy/ or patient advocacy/
16 Advocacy.tw.
17 mentor$.tw.
18 Crisis Intervention.tw.
19 counsel$.tw.
20 social work$.tw.
21 risk assessment.tw.
22 social welfare.tw.
23 social support.tw.
24 help seeking.tw.
25 information giving.tw.
26 giv$ information.tw.
27 advice giving.tw.
28 giv$ advice.tw.
29 patient educat$.tw.
30 health educat$.tw.
31 safety.tw.
32 womens health.tw.
33 or/4-32
34 3 and 33

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Maternity and Infant Care* (Ovid)
1971 to September 2011. Searched 3 October 2011. Limited by publication year [458 records]
1971 to February 2013. Searched 7 March 2013. Limited by date added [178 records]
1971 to January 2014. Searched 7 March 2014. Limited by date added [70 records]
1971 to January 2015. Searched 23 April 2015. Limited by date added [0 records]
1 battered women.tw.
2 Domestic violence.de.
3 (abus$ adj3 (women or woman or spous$)).tw.
4 (ABUS$ adj3 (PARTNER$ or WIFE or WIVES)).tw.
5 (BATTER$ adj3 (PARTNER$ or WIFE or WIVES)).tw.
6 (batter$ adj3 (women or woman or spous$)).tw.
7 (VIOLEN$ adj3 (PARTNER$ or WIFE or WIVES)).tw.
8 (violen$ adj3 (woman or women or spous$)).tw.
9 (violen$ adj3 dat$).tw.
10 or/1-9
11 Child abuse.de.
12 (child adj3 abus$).tw.
13 11 or 12
14 10 not 13
15 limit 14 to yr=“2007 - Current” (Limits applied October 2011)
16 limit 14 to up=20111005-20130307 (Limits applied March 2013)
17 limit 14 to up=20130301-20140327 (Limits applied March 2014)
18 limit 14 to up=20140301-20150423 (Limits applied April 2015)
*Maternity and Infant Care (MIC) replaces MIDIRS, which was last searched for this review in December 2006. MIDIRS is incorporated
into MIC.

Cochrane Database of Systematic Reviews (CDSR, part of The Cochrane Library)


2014, Issue 4; searched 27 March 2014. All available years were searched [4 records]
2015, Issue 4; searched 23 April 2015. Limited by publication year [4 records]
#1(battered wom*n):ti,ab
#2MeSH descriptor: [Battered Women] explode all trees
#3MeSH descriptor: [Domestic Violence] this term only
#4MeSH descriptor: [Spouse Abuse] this term only
#5(abuse near/3 (woman or women)):ti,ab
#6(abuse* near/3 partner*):ti,ab
#7(abuse* near/3 spouse*):ti,ab
#8(wife near/3 batter* or wives near/3 batter*):ti,ab
#9(wife* near/3 abuse* or wives near/3 abuse*):ti,ab
#10(violen* near/3 partner* or violen* near/3 spous*):ti,ab
#11(violen* near/3 date or violen* near/3 dating):ti,ab
#12#1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11
#13(child next abuse):ti,ab
#14MeSH descriptor: [Child Abuse] this term only
#15MeSH descriptor: [Child Abuse, Sexual] this term only
#16#13 or #14 or #15
#17#12 not #16
#18(wom*n or female*):ti,ab
#19MeSH descriptor: [Women] this term only
#20(adolescen* or teen*):ti,ab
#21MeSH descriptor: [Adolescent] this term only
#22#18 or #19 or #20 or #21
#23advocacy:ti,ab
Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 157
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
#24MeSH descriptor: [Patient Advocacy] this term only
#25MeSH descriptor: [Consumer Advocacy] explode all trees
#26counsel*:ti,ab
#27MeSH descriptor: [Counseling] explode all trees
#28social work:ti,ab
#29MeSH descriptor: [Social Work] explode all trees
#30mentor*:ti,ab
#31MeSH descriptor: [Mentors] this term only
#32crisis intervention:ti,ab
#33MeSH descriptor: [Crisis Intervention] this term only
#34risk assessment:ti,ab
#35MeSH descriptor: [Risk Assessment] this term only
#36MeSH descriptor: [Social Welfare] explode all trees
#37social welfare:ti,ab
#38social support:ti,ab
#39MeSH descriptor: [Social Support] this term only
#40help seeking:ti,ab
#41information giving:ti,ab
#42give near/3 information:ti,ab
#43advice giving:ti,ab
#44(give near/3 advice or giving near/3 advice):ti,ab
#45(patient education):ti,ab
#46MeSH descriptor: [Patient Education as Topic] this term only
#47MeSH descriptor: [Health Education] explode all trees
#48safety:ti,ab 55764
#49MeSH descriptor: [Safety] explode all trees
#50women’s health:ti,ab
#51MeSH descriptor: [Women’s Health] explode all trees
#52#23 or #24 or #25 or #26 or #27 or #28 or #29 or #30 or #31 or #32 or #33 or #34 or #35 or #36 or #37 or #38 or #39 or #40 or
#41 or #42 or #43 or #44 or #45 or #46 or #47 or #48 or #49 or #50 or #51
#53#17 and #22 and #52
#54#53

Database of Abstracts of Reviews of Effects (DARE, part of The Cochrane Library)


2011, Issue 3, searched 4 October 2011. Limited by publication year 2008 to 2011 [2 records]
2013, Issue 1, searched 7 March 2013. Limited by publication year 2011 to 2013 [1 record]
2014, Issue 1, searched 27 March 2014. Limited by publication year 2013 to 2014 [0 records]
2015, Issue 1, searched 23 April 2015. Limited by publication year 2014 to 2015 [0 records]
#1(battered wom*n):ti,ab
#2MeSH descriptor: [Battered Women] explode all trees
#3MeSH descriptor: [Domestic Violence] this term only
#4MeSH descriptor: [Spouse Abuse] this term only
#5(abuse near/3 (woman or women)):ti,ab
#6(abuse* near/3 partner*):ti,ab
#7(abuse* near/3 spouse*):ti,ab
#8(wife near/3 batter* or wives near/3 batter*):ti,ab
#9(wife* near/3 abuse* or wives near/3 abuse*):ti,ab
#10(violen* near/3 partner* or violen* near/3 spous*):ti,ab
#11(violen* near/3 date or violen* near/3 dating):ti,ab
#12#1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11
#13(child next abuse):ti,ab
#14MeSH descriptor: [Child Abuse] this term only
Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 158
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
#15MeSH descriptor: [Child Abuse, Sexual] this term only
#16#13 or #14 or #15
#17#12 not #16
#18(wom*n or female*):ti,ab
#19MeSH descriptor: [Women] this term only
#20(adolescen* or teen*):ti,ab
#21MeSH descriptor: [Adolescent] this term only
#22#18 or #19 or #20 or #21
#23advocacy:ti,ab
#24MeSH descriptor: [Patient Advocacy] this term only
#25MeSH descriptor: [Consumer Advocacy] explode all trees
#26counsel*:ti,ab 6321
#27MeSH descriptor: [Counseling] explode all trees
#28social work:ti,ab
#29MeSH descriptor: [Social Work] explode all trees
#30mentor*:ti,ab
#31MeSH descriptor: [Mentors] this term only
#32crisis intervention:ti,ab
#33MeSH descriptor: [Crisis Intervention] this term only
#34risk assessment:ti,ab
#35MeSH descriptor: [Risk Assessment] this term only
#36MeSH descriptor: [Social Welfare] explode all trees
#37social welfare:ti,ab
#38social support:ti,ab
#39MeSH descriptor: [Social Support] this term only
#40help seeking:ti,ab
#41information giving:ti,ab
#42give near/3 information:ti,ab
#43advice giving:ti,ab
#44(give near/3 advice or giving near/3 advice):ti,ab
#45(patient education):ti,ab
#46MeSH descriptor: [Patient Education as Topic] this term only
#47MeSH descriptor: [Health Education] explode all trees
#48safety:ti,ab 55764
#49MeSH descriptor: [Safety] explode all trees
#50women’s health:ti,ab
#51MeSH descriptor: [Women’s Health] explode all trees
#52#23 or #24 or #25 or #26 or #27 or #28 or #29 or #30 or #31 or #32 or #33 or #34 or #35 or #36 or #37 or #38 or #39 or #40 or
#41 or #42 or #43 or #44 or #45 or #46 or #47 or #48 or #49 or #50 or #51
#53#17 and #22 and #52
#54#53

metaRegister of Controlled Trials (mRCT)


(isrctn.com/page/mrct)
Searched 5 October 2011. No date limits [72 records]
Searched 8 March 2013. No date limits [90 records]
Searched 28 March 2014. No date limits [0 new records]
Searched 23 April 2015. No date limits [55 records]
“intimate partner violence” OR “domestic violence”

WHO International Clinical Trials Registry Platform (ICTRP)

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 159
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
apps.who.int/trialsearch)
Searched 15 April 2015 [55 records]
Condition: domestic violen* OR domestic abus* OR partner violen* OR partner abus* OR spouse violen* or spouse abus* OR battered
women

UK Clinical Research Network Study Portfolio* (UKCRN)


(public.ukcrn.org.uk/search)
Searched 29 September 2011. No date limits [7 records]
Searched 8 March 2013. No date limits [10 records]
Searched 28 March 2014. No date limits [2 new records]
Searched 23 April 2015. No date limits [3 new records]
Domestic violence ( Title)
IPV ( Title)
Domestic violence (Research summary)
IPV (Research summary)
* UKCRN replaced the National Research Register (NRR). The NRR was last searched for this review in December 2006.

Appendix 2. Search strategies up to 2008


The searches were originally run by Danielle Dunne and Carol Rivas.They were then run again (to July 2008) by Jo Abbott (Cochrane
Review Group) and Jean Ramsay.

CENTRAL AND DARE (part of The Cochrane Library)


2008, Issue 3
1.Battered Women in Title, Abstract or Keywords
2.Spouse Abuse in Title, Abstract or Keywords
3.Domestic Violence in Title, Abstract or Keywords
4.abuse* near/3 wom*n in Title, Abstract or Keywords
5.abuse* near/3 partner* in Title, Abstract or Keywords
6.abuse* near/3 spous* in Title, Abstract or Keywords
7.(wife or wives) near/3 batter* in Title, Abstract or Keywords
8.(wife or wives) near/3 abuse* in Title, Abstract or Keywords
9.partner* near/3 violen* in Title, Abstract or Keywords
10.spous* near/3 violen* in Title, Abstract or Keywords
11.dat* near/3 violen* in Title, Abstract or Keywords
12.(#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11)
13.Child Abuse in Title, Abstract or Keywords
14.Child Abuse, Sexual in Title, Abstract or Keywords
15.(#13 OR #14)
16.(#12 AND NOT #15)

Ovid MEDLINE
1966 to 31 July 2008
1.(BATTERED ADJ WOMEN).TI,AB.
2.BATTERED-WOMEN.MJ. OR SPOUSE-ABUSE.MJ. OR DOMESTIC-VIOLENCE.MJ.
3.(ABUSE$3 NEAR WOM$3).TI,AB.
4.(ABUSE$ NEAR PARTNER$).TI,AB.
5.(ABUSE$ NEAR SPOUS$).TI,AB.
6.((WIFE OR WIVES) NEAR BATTER$).TI,AB.
Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 160
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
7.((WIFE OR WIVES) NEAR ABUSE$).TI,AB.
8.(VIOLEN$ NEAR PARTNER$).TI,AB.
9.(VIOLEN$ NEAR SPOUS$).TI,AB.
10.(VIOLEN$ NEAR (DATE OR DATING)).TI,AB.
11.1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10
12.(CHILD ADJ ABUSE).TI,AB.
13.CHILD-ABUSE.MJ. OR CHILD-ABUSE-SEXUAL.MJ.
14.11 NOT (12 OR 13)15.(WOM$3 OR FEMALE$3).TI,AB.
16.WOMEN.MJ. OR FEMALE.MJ.
17.(ADOLESCEN$ OR TEEN$).TI,AB.
18.ADOLESCENT.MJ.19.15 OR 16 OR 17 OR 18
20.ADVOCACY.TI,AB.
21.PATIENT-ADVOCACY#.DE. OR CONSUMER-ADVOCACY#.DE.
22.COUNSEL$.TI,AB.
23.COUNSELING#.W..DE.
24.(SOCIAL ADJ WORK).TI,AB.
25.SOCIAL-WORK#.DE.
26.MENTOR$.TI,AB.
27.MENTORS#.W..DE.
28.(CRISIS ADJ INTERVENTION).TI,AB.
29.CRISIS-INTERVENTION#.DE.30.(RISK ADJ ASSESSMENT).TI,AB.
31.RISK-ASSESSMENT#.DE.
32.(SOCIAL ADJ WELFARE).TI,AB.
33.SOCIAL-WELFARE#.DE.
34.(SOCIAL ADJ SUPPORT).TI,AB.
35.SOCIAL-SUPPORT#.DE.
36.(HELP ADJ SEEKING).TI,AB.
37.(INFORMATION ADJ GIVING).TI,AB.
38.(GIV$3 ADJ INFORMATION).TI,AB.
39.(ADVICE ADJ GIVING).TI,AB.
40.(GIV$3 ADJ ADVICE).TI,AB.
41.(PATIENT ADJ EDUCATION).TI,AB.
42.PATIENT-EDUCATION#.DE.
43.HEALTH-EDUCATION#.DE.
44.SAFETY.TI,AB.
45.SAFETY#.DE.
46.(WOMENS ADJ HEALTH).TI,AB.
47.WOMENS-HEALTH#.DE.
48.20 OR 21 OR 22 OR 23 OR 24 OR 25 OR 26 OR 27 OR 28 OR 29 OR 30 OR 31 OR 32 OR 33 OR 34 OR 35 OR 36 OR
37 OR 38 OR 39 OR 40 OR 41 OR 42 OR 43 OR 44 OR 45 OR 46 OR 47
49.14 AND 19 AND 48

EMBASE (Ovid)
1980 to week 30 2008
1. (BATTERED ADJ WOMEN).TI,AB.
2.BATTERED-WOMAN.MJ. OR PARTNER-VIOLENCE.MJ. OR DOMESTIC-VIOLENCE.MJ. OR FAMILY-VIO-
LENCE.MJ. OR BATTERING.W..MJ.
3.(ABUSE$ NEAR WOM$).TI,AB.
4.(ABUSE$ NEAR PARTNER$).TI,AB.
5.(ABUSE$ NEAR SPOUS$).TI,AB.
6.((WIFE OR WIVES) NEAR BATTER$).TI,AB.
7.((WIFE OR WIVES) NEAR ABUSE$).TI,AB.
Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 161
intimate partner abuse (Review)
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8.(VIOLEN$ NEAR PARTNER$).TI,AB.
9.(VIOLEN$ NEAR SPOUS$).TI,AB.
10.(VIOLEN$ NEAR (DATE OR DATING)).TI,AB.
11.1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10
12.(CHILD ADJ ABUSE).TI,AB.
13.CHILD-ABUSE.MJ.
14.CHILD-SEXUAL-ABUSE.MJ.
15.11 NOT (12 OR 13 OR 14)
16.(WOM$3 OR FEMALE$3).TI,AB.
17.WOMEN.MJ.
18.FEMALE.MJ.
19.(ADOLESCEN$ OR TEEN$).TI,AB.
20.16 OR 17 OR 18 OR 19
21.ADVOCACY.TI,AB.
22.PATIENT-ADVOCACY#.W..DE.
23.CONSUMER-ADVOCACY#.W..DE.
24.COUNSEL$.TI,AB.
25.PATIENT-COUNSELING#.W..DE.
26.(SOCIAL ADJ WORK).TI,AB.
27.SOCIAL-WORK#.DE.
28.MENTOR$.TI,AB.
29.(CRISIS ADJ INTERVENTION).TI,AB.
30.CRISIS-INTERVENTION#.DE.
31.(RISK ADJ ASSESSMENT).TI,AB.
32.RISK-ASSESSMENT#.DE.
33.(SOCIAL ADJ WELFARE).TI,AB.
34.SOCIAL-WELFARE#.DE.
35.(SOCIAL ADJ SUPPORT).TI,AB.
36.SOCIAL-SUPPORT#.DE.
37.(HELP ADJ SEEKING).TI,AB.
38.HELP-SEEKING-BEHAVIOR#.DE.
39.(INFORMATION ADJ GIVING).TI,AB.
40.MEDICAL-INFORMATION#.DE.
41.(GIV$3 ADJ INFORMATION).TI,AB.
42.(ADVICE ADJ GIVING).TI,AB.
43.(GIV$3 ADJ ADVICE).TI,AB.
44.(PATIENT ADJ EDUCATION).TI,AB.
45.PATIENT-EDUCATION#.DE. OR HEALTH-EDUCATION#.DE.
46.SAFETY.TI,AB.47.SAFETY#.DE.
48.PATIENT-SAFETY#.DE.
49.(WOMENS ADJ HEALTH).TI,AB.
50.21 OR 22 OR 23 OR 24 OR 25 OR 26 OR 27 OR 28 OR 29 OR 30 OR 31 OR 32 OR 33 OR 34 OR 35 OR 36 OR 37 OR
38 OR 39 OR 40 OR 41 OR 42 OR 43 OR 44 OR 45 OR 46 OR 47 OR 48 OR 49
51.15 AND 20 AND 50

PsycINFO (Ovid)
1806 to week 4 2008
1.(BATTERED ADJ WOMEN).TI,AB.
2.BATTERED-FEMALES.MJ. OR DOMESTIC-VIOLENCE.MJ. OR PARTNER-ABUSE.MJ.
3.(ABUSE$3 NEAR WOM$3).TI,AB.
4.(ABUSE$3 NEAR PARTNER$3).TI,AB.
5.(ABUSE$3 NEAR SPOUS$3).TI,AB.
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6.(WIFE OR WIVES) NEAR BATTER$3.TI,AB.
7.(WIFE OR WIVES) NEAR ABUSE$3.TI,AB.
8.(VIOLEN$3 NEAR PARTNER$3).TI,AB.
9.(VIOLEN$3 NEAR SPOUS$3).TI,AB.
10.(VIOLEN$3 NEAR (DATE OR DATING)).TI,AB.
11.1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10
12.(CHILD ADJ ABUSE).TI,AB.
13.CHILD-ABUSE.MJ.
14.(CHILD$ NEAR ABUSE NEAR SEXUAL).TI,AB.
15.11 NOT (12 OR 13 OR 14)
16.(WOM$3 OR FEMALE$3).TI,AB.
17.(HUMAN-FEMALES OR MOTHERS).MJ.
18.(ADOLESCEN$3 OR TEEN$3).TI,AB.
19.16 OR 17 OR 18
20.ADVOCACY.TI,AB.
21.ADVOCACY#.W..DE.
22.COUNSEL$4.TI,AB.
23.COUNSELING#.W..DE.
24.(SOCIAL ADJ WORK).TI,AB.
25.MENTOR$3.TI,AB.
26.MENTOR#.W..DE.
27.(CRISIS ADJ INTERVENTION).TI,AB.
28.CRISIS-INTERVENTION#.DE. OR CRISIS-INTERVENTION-SERVICES#.DE.
29.(RISK ADJ ASSESSMENT).TI,AB.
30.RISK-ASSESSMENT#.DE.
31.(SOCIAL ADJ WELFARE).TI,AB.
32.SOCIAL-CASEWORK#.DE.
33.(SOCIAL ADJ SUPPORT).TI,AB.
34.SOCIAL-SUPPORT#.DE.
5.(HELP ADJ SEEKING).TI,AB.
36.HELP-SEEKING-BEHAVIOR#.DE.
37.(GIV$3 NEAR INFORMATION).TI,AB.
38.(GIV$3 NEAR ADVICE).TI,AB.
39.(PATIENT ADJ EDUCATION).TI,AB.
40.CLIENT-EDUCATION#.DE. OR HEALTH-EDUCATION#.DE.
41.SAFETY.TI,AB.
42.SAFETY#.W..DE.
43.(WOMENS ADJ HEALTH).TI,AB.
44.20 OR 21 OR 22 OR 23 OR 24 OR 25 OR 26 OR 27 OR 28 OR 29 OR 30 OR 31 OR 32 OR 33 OR 34 OR 35 OR 36 OR
37 OR 38 OR 39 OR 40 OR 41 OR 42 OR 43
45.15 AND 19 AND 44

CINAHL (Ovid)
1982 to 31 July 2008
1.(BATTERED ADJ WOMEN).TI,AB.
2.BATTERED-WOMEN.MJ. OR PARTNER-ABUSE.MJ. OR DOMESTIC-VIOLENCE.MJ. OR SPOUSE-ABUSE.MJ.
3.(ABUSE$ NEAR (WOM$ OR PARTNER$ OR SPOUS$)).TI,AB.
4.((WIFE OR WIVES) NEAR (BATTER$ OR ABUSE$)).TI,AB.
5.(VIOLEN$ NEAR (PARTNER$ OR SPOUS$ OR DATE OR DATING)).TI,AB.
6.1 OR 2 OR 3 OR 4 OR 5
7.(CHILD ADJ ABUSE).TI,AB.
8.CHILD-ABUSE.MJ. OR CHILD-ABUSE-SEXUAL.MJ.
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9.6 NOT (7 OR 8)
10.(WOM$ OR FEMALE$).TI,AB.
11.WOMEN.W..MJ.
12.MOTHER$.TI,AB.
13.MOTHERS.W..MJ.
14.(ADOLESCEN$ OR TEEN$).TI,AB.
15.10 OR 11 OR 12 OR 13 OR 14
16.ADVOCACY.TI,AB.
17.PATIENT-ADVOCACY#.DE. OR CONSUMER-ADVOCACY#.DE.
18.COUNSEL$.TI,AB.
19.COUNSELING#.W..DE.
20.MENTOR$.TI,AB.
21.MENTORSHIP#.W..DE.
22.(CRISIS ADJ INTERVENTION).TI,AB.
23.CRISIS-INTERVENTION#.DE.
24.(RISK ADJ ASSESSMENT).TI,AB.
25.RISK-ASSESSMENT#.DE.
26.(SOCIAL ADJ WELFARE).TI,AB.
27.SOCIAL-WELFARE#.DE.
28.(SOCIAL ADJ SUPPORT).TI,AB.
29.SUPPORT-PSYCHOSOCIAL#.DE. OR SOCIAL-NETWORKS#.DE.
30.(HELP ADJ SEEKING).TI,AB.
31.HELP-SEEKING-BEHAVIOR#.DE.
32.(GIV$ ADJ (INFORMATION OR ADVICE)).TI,AB.
33.PATIENT-EDUCATION#.DE.
34.(HEALTH ADJ EDUCATION).TI,AB.
35.HEALTH-EDUCATION#.DE.
36.SAFETY.TI,AB.
37.SAFETY#.W..DE. OR PATIENT-SAFETY#.DE.
38.(SOCIAL ADJ WORK).TI,AB.
39.SOCIAL-WORK#.DE.(WOMENS ADJ HEALTH).TI,AB.
40.WOMENS-HEALTH#.DE.
41.(WOMENS ADJ HEALTH ADJ SERVICES).TI,AB.
42.WOMENS-HEALTH-SERVICES#.DE.
43.16 OR 17 OR 18 OR 19 OR 20 OR 21 OR 22 OR 23 OR 24 OR 25 OR 26 OR 27 OR 28 OR 29 OR 30 OR 31 OR 32 OR
33 OR 34 OR 35 OR 36 OR 37 OR 38 OR 39 OR 40 OR 41 OR 42
44.9 AND 15 AND 43

ASSIA (Cambridge Scientific Abstracts)


1987 to 31 July 2008
((KW=((abuse* within 3 (wom?n or partner* or spous* or wife or wives)) or (batter* within 3 (wom?n or partner* or spous* or wife
or wives)) or (violen* within 3 (wom?n or partner* or spous* or wife or wives))) or KW=((family violence) or (domestic violence) or
(dat* violence)) and not KW=((child* within 3 abuse) or (child* within 3 sex* within 3 abuse) or (child* within 3 maltreatment)))
and (KW=((wom?n or female* or mother*) or (adolescen* or teen*))) and (KW=((advocacy or counsel* or mentor*) or (crisis within 3
(intervention or management)) or (risk within 3 assessment)) or KW=((social within 3 (support or welfare)) or (help within 3 seek*)
or (giv* within 3 (information or advice))) or KW=((safety) or (education within 3 (patient or health))))

Social Science Citation Index (SSCI; Web of Science)


1987 to 31 July 2008
#40 # 39 AND #27 AND #22
#39 #38 OR #37 OR #36 OR #35 OR #34 OR #33 OR #32 OR #31 OR #30 OR #29 OR #28
Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 164
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#38 TS=(safety)
#37 TS=(Patient same Education)
#36 TS=(giv* same advice)
#35 TS=(giv* same information)
#34 TS=(help* same seek*)
#33 TS==(Social same Support)
#32 TS=(social welfare)
#31 TS=(Risk same Assessment)
#30 TS=(mentor*)
#29 TS=(counsel*)
#28 TS=advoca*
#27 #26 OR #25 OR #24 OR #23
#26 TS=wom*n
#25 TS=female*
#24 TS=(mother*)
#23 TS=(adolescen* or teen*)
#22 #20 NOT #21
#21 #19 OR #18
#20 #17 OR #16 OR #15 OR #14 OR #13 OR #12 OR #11 OR #10 OR #9 OR #8 OR #7 OR #6 OR #5 OR #4 OR #3 OR #2
OR #1
#19 TS=(child* SAME abuse* SAME sexual*)
#18 TS==(child same abuse)
#17 TS=(dat* SAME violen*)
#16 TS=(domestic violence)
#15 TS=(violen* wives)
#14 TS=(violen* SAME wife)
#13 TS=(violen* SAME partner*)
#12 TS=(violen* SAME spous*)
#11 TS=(violen* SAME wom*n)
#10 TS=(abuse* wives)
#9 TS=(abuse* SAME wife)
#8 TS=(abuse* SAME partner*)
#7 TS=(abuse* SAME spous*)
#6 TS=(abuse* SAME wom*n)
5 TS=(batter* wives)
#4 TS=(batter* SAME wife)
#3 TS=(batter* SAME partner*)
#2 TS=(batter* SAME spous*)
#1 TS=(batter* SAME wom*n)

International Bibliography of Social Sciences (IBSS; Ovid)


1951 to July week 4 2008
1.(batter$ adj3 wom#n).mp. [mp=abstract, title, subject heading, geographic heading]
2.(batter$ adj3 spous$).mp. [mp=abstract, title, subject heading, geographic heading]
3.(batter$ adj3 partner$).mp. [mp=abstract, title, subject heading, geographic heading]
4.(batter$ adj3 wife).mp. [mp=abstract, title, subject heading, geographic heading]
5.(batter$ adj3 wives).mp. [mp=abstract, title, subject heading, geographic heading]
6.(abuse$ adj3 wom#n).mp. [mp=abstract, title, subject heading, geographic heading]
7.(abuse$ adj3 spous$).mp. [mp=abstract, title, subject heading, geographic heading]
8.(abuse$ adj3 partner$).mp. [mp=abstract, title, subject heading, geographic heading]
9.(abuse$ adj3 wife).mp. [mp=abstract, title, subject heading, geographic heading]
10.(abuse$ adj3 wives).mp. [mp=abstract, title, subject heading, geographic heading]
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Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
11.(violen$ adj3 wom#n).mp. [mp=abstract, title, subject heading, geographic heading]
12.(violen$ adj3 spous$).mp. [mp=abstract, title, subject heading, geographic heading]
13.(violen$ adj3 partner$).mp. [mp=abstract, title, subject heading, geographic heading]
14.(violen$ adj3 wife).mp. [mp=abstract, title, subject heading, geographic heading]
15.(violen$ adj3 wives).mp. [mp=abstract, title, subject heading, geographic heading]
16.domestic violence.mp. [mp=abstract, title, subject heading, geographic heading]
17.(dat$ adj3 violen$).mp. [mp=abstract, title, subject heading, geographic heading]
18.(child adj3 abuse).mp. [mp=abstract, title, subject heading, geographic heading]
19.(Child$ adj3 abuse adj3 sexual$).mp. [mp=abstract, title, subject heading, geographic heading]
20.1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17
21.20 not (18 or 19)
22.(wom#n or female$).mp. [mp=abstract, title, subject heading, geographic heading]
23.(adolescen$ or teen$).mp. [mp=abstract, title, subject heading, geographic heading]
24.22 or 23
25.advoca$.mp. [mp=abstract, title, subject heading, geographic heading]
26.counsel$.mp. [mp=abstract, title, subject heading, geographic heading]
27.mentor$.mp. [mp=abstract, title, subject heading, geographic heading]
28.(Crisis adj3 Intervention).mp. [mp=abstract, title, subject heading, geographic heading]
29.(Risk adj3 Assessment).mp. [mp=abstract, title, subject heading, geographic heading]
30.Social Welfare.mp. [mp=abstract, title, subject heading, geographic heading]
31.(Social adj3 Support).mp. [mp=abstract, title, subject heading, geographic heading]
32.(help$ adj3 seek$).mp. [mp=abstract, title, subject heading, geographic heading]
33.(giv$ adj3 information).mp. [mp=abstract, title, subject heading, geographic heading]
34.(giv$ adj3 advice).mp. [mp=abstract, title, subject heading, geographic heading]
35.(information giving or (giv$ adj3 information)).mp. [mp=abstract, title, subject heading, geographic heading]
36.(advice giving or (giv$ adj3 advice)).mp. [mp=abstract, title, subject heading, geographic heading]
37.(Patient adj3 Education).mp. [mp=abstract, title, subject heading, geographic heading]
38.(safety or safety behav$).mp. [mp=abstract, title, subject heading, geographic heading]
39.(Health adj3 Education).mp. [mp=abstract, title, subject heading, geographic heading]
40.25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39
41.21 and 24 and 40

British Nursing Index (BNI)


1994 to 18 August 2008
1.(BATTERED ADJ WOMEN).TI,AB.
2.DOMESTIC-VIOLENCE.DE.
3.(ABUS$ NEAR (WOM$ OR SPOUS$)).TI,AB.
4.(ABUS$ NEAR (PARTNER$ OR WIFE OR WIVES)).TI,AB.
5.(BATTER$ NEAR (PARTNER$ OR WIFE OR WIVES)).TI,AB.
6.(BATTER$ NEAR (WOM$ OR SPOUS$)).TI,AB.
7.(VIOLEN$ NEAR (PARTNER$ OR WIFE OR WIVES)).TI,AB.
8.(VIOLEN$ NEAR (WOM$ OR SPOUS$)).TI,AB.
9.(VIOLEN$3 NEAR DAT$3).TI,AB.
10.1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9
11.(CHILD ADJ ABUSE).TI,AB.
12.CHILD-ABUSE-AND-NEGLECT.DE. OR CHILD-ABUSE-SEXUAL.DE.
13.10 NOT (11 OR 12)

Midwives Information and Resource Index (MIDIRS)


1986 to December 2006
Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 166
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Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(batter* or abuse* or violen*) and (wom* or spous* or partner* or wife or wives or domestic or dating) and not (child* abuse or child*
sexual abuse)

National Research Register (NRR)


December 2006 (Issue 4). The NRR ceased to be updated after December 2007 and is no longer available. It was replaced by the UK
Clinical Research Network Study Portfolio* (UKCRN) (public.ukcrn.org.uk/search)
1.((batter* near woman) or (batter* near women) or (batter* near spouse) or (batter* near wife) or (batter* near wives) or (batter* near
partner))
2.((abuse* near woman) or (abuse* near women) or (abuse* near spouse) or (abuse* near wife) or (abuse* near wives) or (abuse* near
partner))
3.((violen* near woman) or (violen* near women) or (violen* near spouse) or (violen* near wife) or (violen* near wives) or (violen*
near partner))
4.((violen* near dat*) or (domestic near violence) or (family near violence))
5.((child* near abuse*) or (child* near sex* near abuse*))
6.(#1 or #2 or #3 or #4)
7.(#6 and (not #5))

WHAT’S NEW
Last assessed as up-to-date: 13 April 2015.

Date Event Description

6 March 2015 New citation required but conclusions have not changed Three new studies included in the review

6 March 2015 New search has been performed The review was updated following new searches in
September 2011, March 2013, March 2014, and most
recently, April 2015

HISTORY
Protocol first published: Issue 1, 2005
Review first published: Issue 3, 2009

Date Event Description

27 March 2014 New search has been performed Searches updated

24 September 2013 New search has been performed Draft updated review finalised

7 March 2013 New search has been performed Searches updated

20 September 2012 Amended Author line amended

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 167
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(Continued)

30 September 2011 New search has been performed Searches updated

24 July 2009 Amended Author line correction

16 July 2008 Amended Converted to new review format.

20 September 2007 New citation required and conclusions have changed Substantive amendment

CONTRIBUTIONS OF AUTHORS
For the original review, Jean Ramsay wrote the protocol, searched databases, selected papers, extracted data from papers, entered and
analysed data, wrote the first draft of the review, and edited the text. Gene Feder edited the protocol, selected papers, extracted data
from papers, analysed data and edited the text of the review. Carol Rivas and Danielle Dunne searched databases, selected papers,
extracted data from papers, considered the results, and edited the text of the review. Sandra Eldridge provided statistical guidance and
edited the text of the review. Yvonne Carter, Leslie Davidson, Kelsey Hegarty, Angela Taft, and Alison Warburton edited the protocol,
considered the results, and edited the text of the review.
For the updated review, Carol Rivas selected papers, extracted data from papers, entered and analysed data, produced the first draft
of the ’Summary of findings’ table and associated text, and edited the text of the review. Jean Ramsay reviewed the protocol, searched
databases, selected papers, extracted data from papers, entered and analysed data, wrote the first draft of the review, and edited the text.
Laura Sadowski selected papers, extracted data from papers, analysed data, and edited the text of the review. Sandra Eldridge advised
on inclusion queries, provided statistical guidance and edited the text of the review. Gene Feder reviewed the protocol, adjudicated on
inclusion disagreements, and edited the text of the review. Leslie Davidson, Danielle Dunne, Kelsey Hegarty, and Angela Taft advised
on inclusion queries, considered the results, and edited the text of the review. Angela and Kelsey were not involved with inclusion
queries or results of the Taft 2011 and 2009 studies that they were involved in. Leslie Davidson contacted included authors to check
our list of studies.

DECLARATIONS OF INTEREST
Carol Rivas was partly funded by the National Institute for Health Research (NIHR) applied research programme funding stream. The
views and opinions do not not necessarily reflect those of the NIHR, NHS, or the Department of Health (England).
Gene Feder and Jean Ramsay’s institution received payment from Socialforsksnings Institut (SFI) Nordic Campbell Centre Denmark,
for submitting an edited version of the 2009 review to the Campbell Collaboration.
Laura Sadowski has received funds for her participation in reviewing the evidence of interventions to reduce intimate partner violence
for the British Medical Journal (BMJ) and the World Health Organization (WHO).
Leslie Davidson - none known.
Danielle Dunne - none known.
Kelsey Hegarty’s institution received funds from the National Health and Medical Research Council (NHMRC) for her work on
Hegarty 2013. Kelsey received funds from a General Practice in Victoria for a training programme on intimate partner violence for
general practitioners. Kelsey has also received funds for expenses from WHO, for her work in a guideline group on intimate partner
violence.
Angela Taft and Kelsey Hegarty declare they are authors on Taft 2011 and had no part in the assessment of eligibility, assessment of
risk of bias or data extraction of this study. Angela received funds from National Health and Medical Research Council to conduct the
MOSAIC trial and funds from the Australian Research Council and VicHealth to conduct the MOVE trial (bit.ly/1fpQPFw).
Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 168
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Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Gene Feder, Sandra Eldridge and Jean Ramsay are authors of the Feder 2011 trial, which was not eligible for inclusion in this review.
Cathy Bennett and Carol Rivas assessed the eligibility of studies for inclusion. Gene was not required to resolve any disagreements with
regards to this trial. Gene is part of the steering group for Identification and Referral to Improve Safety (IRIS), a programme that can
be commissioned in the United Kingdom to train general practices and provide a referral pathway to advocacy for women experiencing
domestic violence. His employer, the University of Bristol, receives an annual consultancy fee for his involvement with IRIS. The study
was not included in this review update. Gene is a Principal Investigator on domestic violence research studies, funded by grants to his
University from the National Institute of Health Research, the UK Department of Health Policy Research Programme and the National
School for Primary Care Research. Gene and his organisation receives funds for his consultancy work with the National Institute for
Health and Care Excellence (NICE) and for chairing the Domestic Violence Programme Development Group there. He has received
royalties for an academic book on domestic violence and health. Gene’s university has received fees from the Health Foundation for
domestic violence educational programmes that he has developed.

SOURCES OF SUPPORT

Internal sources
• No sources of support supplied

External sources
• Socialforsksnings Institut (SFI) Nordic Campbell Centre, Denmark.
(Original review only, not the 2013 update) - funding support to enable co-registration of the review within the Campbell
Collaboration (DOI:10.4073/csr.2009.5)
• National Institute of Health Research, UK.
Carol Rivas’s contribution was partly funded by the NIHR applied research programme funding stream. The views and opinions do
not not necessarily reflect those of the NIHR, NHS or the Department of Health (England).
• Queen Mary University of London, UK.
Danielle Dunne worked on the update of this review whilst employed full-time at Queen Mary University of London

DIFFERENCES BETWEEN PROTOCOL AND REVIEW

2009 review
In our protocol we stated that we would search the criminal justice electronic databases but ultimately this was not possible. The process
of searching these databases proved unhelpful due to the use of terms with vastly different meanings in the justice disciplines (such as
trial or control).
A further difference relates to some of the outcome measures that we analysed. In the review, we included four outcomes that were not
mentioned in the protocol but which we subsequently decided were of interest: risk of homicide, work harassment, independence from
abuser, and emotional attachment to the abuser. Additionally, we had not anticipated that the use of resources by participants would
be measured using a composite scale, rather than individual measures of the various resources available.

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 169
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2015 update to review
In our protocol, we stated that we would include studies where advocacy was evaluated as an adjunct to another intervention, but on
the proviso that advocacy was the only difference between the two trial arms. In the updated review, however, we have also included
trials where women in the intervention arm may have received advocacy plus some other form of intervention compared with no care
or usual care. The review team judged that this change was necessary given the increasing number of trials evaluating advocacy within
the context of multi-component interventions. Similar considerations would be given to studies with multiple eligible arms or multiple
control conditions in a single trial, so long as the inclusion criteria are met and results for advocacy are available separately.
A further change from the original 2009 review relates to our definition of ’usual care’. Originally we specified that we would include
all studies where advocacy was compared with no care or usual care. However, increasingly usual care can sometimes incorporate
elements of advocacy. For the purposes of evaluating the effectiveness of advocacy interventions more rigorously, in the updated review
we excluded any studies where usual care included a substantial element of advocacy and was received by more than 20% of women
in the control arm. Again, the review team judged that this change was necessary given the increasing use of advocacy as a usual care
treatment.
Moreover, this update includes trials in which the unit of analysis is not the woman. We have updated our methods section accordingly.
A further difference relates to some of the outcome measures that we analysed. We had not anticipated that the use of resources by
participants would be measured using a composite scale, rather than individual measures of the various resources available, and we
have included this aspect in both the 2009 and 2015 updates. In the 2009 review we included four outcomes that were not mentioned
in the protocol but which we subsequently decided were of interest: risk of homicide, work harassment, independence from abuser,
emotional attachment to the abuser. In the 2015 update we also added perceived stress to this list. Additionally, for the current 2015
update, we had not predicted that abuse might be assessed using a composite scale (overall abuse) rather than discrete measures of the
different forms of intimate partner abuse, and so we included this outcome also.
In our protocol, assessment of risk of bias of included studies did not include the item ‘contamination’, which is now included.
We originally stated that a fixed-effect model would only be used if there was no significant statistical heterogeneity. However the
following analyses, performed with a fixed-effect model, have moderate/high statistical heterogeneity: Analysis 3.1 (I² = 51%), Analysis
4.1 (I² = 58%), Analysis 7.2 (I² = 72%), Analysis 7.2.2 (I² = 56%), Analysis Analysis 7.2.3 (I² = 72%), Analysis 7.2.7 (I² = 81%), and
Analysis 23.1 (I² = 97%). This heterogeneity is due to the confidence intervals crossing 0 or 1 (depending on the analysis), so using a
random-effects model would not change the conclusions.

NOTES
This review is co-registered within the Campbell Collaboration.

INDEX TERMS

Medical Subject Headings (MeSH)


∗ Counseling; ∗ Safety; ∗ Social
Welfare; Depression [therapy]; Quality of Life; Randomized Controlled Trials as Topic; Social Work;
Spouse Abuse [∗ prevention & control; psychology; therapy]; Time Factors

MeSH check words


Female; Humans; Pregnancy

Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience 170
intimate partner abuse (Review)
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.