Advocacy Interventions to Reduce or Eliminate Violence and Promote the Physical and Psychosocial Well-Being of Women who Experience Intimate Partner Abuse: A Systematic Review

Incidence of any form of abuse

1.

Physical

Abuse could be assessed using self-reported measures (such as Composite Abuse Scale (CAS; Hegarty 2005), Index of Spouse 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 of abuse in medical or police records.

Psychosocial health

1.

Quality of life (measures such as 36-item Short Form Health Survey, or SF-3; Ware 1992)

Physical health

1.

Deaths, all-cause and partner abuse-related (documented in medical/police records or regional and national databases)

Psychosocial health

1.

Post-traumatic stress (measures such as Impact of Events scale, or IES; Horowitz 1979)

Socioeconomic outcome measures

1.

Income

‘Proxy’ or intermediate outcome measures (including uptake 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 emergency money)

We recognised that postintervention changes in some of these proxy measures may be associated with both positive and negative health outcomes for abused women and require careful interpretation. For instance, increased refuge/shelter usage may reflect proactive behaviour on the behalf of abused women, but it may also reflect an escalation of violence that has led to the women needing to seek safety. Where authors reported any adverse outcomes from interventions, we recorded and discussed them in the narrative summary.

Baseline measurement of outcome measures

Description: Studies contained information on the comparability of the groups in terms of the primary outcome measures at baseline.

Review authors' judgements: Were the primary outcomes comparable between groups at baseline?

Ratings: Low risk of bias, high risk of bias, or unclear risk of bias.

Reliability of primary outcome measures

Description: Investigators assessed the primary outcomes using reliable measures (e.g. Cronbach's alpha 0.6 or above).

Review authors' judgements: Did investigators assess the primary outcomes using reliable measures?

Ratings: Low risk of bias, high risk of bias, or unclear risk of bias.

Protection against contamination

Description: Investigators described any measures taken to prevent or minimise the possibility that women in the control arm might receive part or all of the intervention so as to assess possible contamination between groups.

Review authors' judgements: Did the study investigators take steps to prevent or minimise contamination?

Ratings: Low risk of bias, high risk of bias, or unclear risk of bias.

Content

The papers did not always explicitly state the theoretical framework underlying each intervention. However, in general, the advocacy provided to the participants was based on the concept of empowerment and included education, advice on safety and accessing resources, and empathic support. All of the interventions were pragmatic in that they provided tailored services to meet the wants and needs of the individual women. Some used the term ‘counselling’, ‘supportive listening’ or ‘peer counselling’ to describe facilitation of access to resources. Thus, Gillum 2009 gave resource information to participants in the control arm, while advocates actively helped to engage women in the intervention group with resources as part of an intervention, thus fitting our criteria.

Tiwari 2010 used an empowerment intervention with a complementary focus on accessing resources. Authors explicitly stated, “The aim of empowerment training is to increase women's safety through the recognition of increased danger, paired with a safety plan developed for individual use. In addition, it provides information about the cycle of violence, facts, and options regarding partner violence, legal protection orders, filing for criminal charges, and community resources for abused women.” Thus, this multi-component, heterogeneous intervention entailed resource identification and facilitated their access to women in the intervention arm, hence fulfilling our inclusion criteria.

One of the studies evaluated a group intervention that allowed for participant-participant interaction, as well as interaction between the intervention participants and the advocate (Constantino 2005). Authors labelled this a ‘social support intervention‘. However, there was no structured psychological intervention, and the intervention focused on accessing community resources, including information on resources and hours of operation for those resources when available. It therefore fits our inclusion criteria. Three trials included components in addition to advocacy that may have impacted the outcomes reported. The first of these included advocacy and education/support for all the children of mothers who had been abused (Sullivan 2002), while the second provided parenting support to all the abused mothers (Taft 2011). The third study was more complex, providing advocacy within the context of three possible further (and separate) interventions, depending on the abused woman's risk profile: cognitive behavioural therapy (CBT) if depression was a risk, and smoking cessation/reduction sessions if smoking or environmental tobacco smoke exposure were identified risks (Kiely 2010).

Advocates

Trained advocates administered all of the interventions, though there was some variability in their professional status. A professional advocate led one of the interventions (Hyman 2001), research nurses administered three others (Constantino 2005; McFarlane 2006; Tiwari 2005), social workers and psychologists provided three others (Cripe 2010; Kiely 2010; Tiwari 2010), and trained paraprofessional students an additional three (Sullivan 1991; Sullivan 1992; Sullivan 2002). One study provided a mixture of face-to-face advocacy with the study investigators plus telephone support from trained community health workers (Gillum 2009). Two studies were somewhat different in that they evaluated the effectiveness of advocacy provided by ‘mentor mothers’. In the first of these, the services of a trained, non-professional ‘mentor mother’ supplemented advocacy by a professional advocate (McFarlane 2000), while in the second, trained, non-professional ‘mentor mothers’ provided the entirety of the intervention (Taft 2011). With one exception, all of the interventions assessed were new and non-established modes of care within the study settings. The exception to this was a trial that evaluated two modes of interventions already in regular use in an emergency room (Hyman 2001).

Duration

The duration of the interventions varied considerably and, to a large extent, was related to the settings in which the women were recruited.

In general, the interventions described in studies outside of healthcare settings were longer, both in terms of the length of the sessions and the period over which the sessions were offered. Typically, these types of interventions took place over a period of two to four months, providing advocacy for respective totals of about 12 hours (Constantino 2005), 43 hours plus an additional 80 hours provided to the children (Sullivan 2002), and 60 to 80 hours (Sullivan 1991; Sullivan 1992). The one exception is the study that recruited women within a community centre setting (Tiwari 2010); an initial face-to-face session (lasting about 30 minutes) was followed by 12 weeks of telephone advocacy (about 10 to 20 minutes per call) for an accumulated total of 2.5 to 4.5 hours of advocacy.

Most interventions recruiting women in healthcare settings were relatively brief. Three interventions were one-off sessions and lasted from 20 to 30 minutes (Tiwari 2005), about 30 minutes (Cripe 2010), and 90 minutes (Hyman 2001). Four other trials offered advocacy sessions over a prolonged period but were still of brief duration overall. In the first of these, women were recruited in antenatal clinics and offered advocacy (or advocacy plus the services of a ‘mentor mother‘) until the time of their delivery (McFarlane 2000). The authors report that most sessions lasted about 30 minutes, with women averaging four to five sessions for an accumulated total of approximately 150 minutes of advocacy (McFarlane 2007 [pers comm]). In the second study, women received five separate 20-minute interventions, each six months apart, for a total of approximately 100 minutes of advocacy (McFarlane 2006). The third trial provided one face-to-face session lasting about 30 minutes, followed by six telephone calls over a three-month period, each lasting an average of 20 minutes (range 5 to 60 minutes) (Woods 2013 [pers comm] in Gillum 2009). We assessed this intervention as being approximately 2.5 hours long. In the fourth study, advocacy for abuse (and where applicable, therapy for depression and smoking/passive smoking) was provided at four to eight prenatal sessions and two postpartum booster sessions (Kiely 2010). Depending on how many of the four risks were addressed, each session lasted 50 ± 15 minutes, for a total of 3.5 to 8 hours of advocacy. The one study recruiting in healthcare clinics that was of longer duration was conducted in Australia (Taft 2011). The total duration of this intervention is not specified in the paper, but abused women were offered a minimum of one hours' advocacy each week for 12 months, for at least 52 total hours of advocacy.

Range of control conditions

Control conditions also varied. One study compared the intervention with usual shelter care and unstructured chats with the principal investigator (Constantino 2005). In five studies, women were provided with a referral card listing useful community agencies (Cripe 2010; Gillum 2009; McFarlane 2000; McFarlane 2006; Tiwari 2005); the women also received health information brochures in two studies (Gillum 2009; McFarlane 2000) and a safety plan in another (McFarlane 2006). In one study, women in the control group also received an information sheet, including community resource details (Taft 2011). In Hyman 2001, the control group received standard care from social services; in Kiely 2010, they received usual prenatal care, and in Sullivan 1991, Sullivan 1992, and Sullivan 2002, they received usual shelter care. In Sullivan 1992, usual after-shelter care was also included within the study. In Tiwari 2010, women in the control group did not receive any specific care; however, recruitment took place at a community centre that provided various community resources, to which they naturally had easy access.

Physical abuse

Physical violence was the most commonly measured form of abuse. When assessing this outcome, five of the trials (Kiely 2010; Sullivan 1991; Sullivan 1992; Tiwari 2005; Tiwari 2010) used modified or revised versions of the physical violence subscale of the Conflict Tactics Scale (CTS, CTS2; Straus 1996). McFarlane 2000 and McFarlane 2006 employed the physical abuse subscale of the Severity of Violence Against Women Scale (SVAWS 1992), Gillum 2009 used the physical abuse subscale of the Partner Abuse Scale (PAS; Hudson 2006), and Hyman 2001 used the physical abuse subscale of the Index of Spouse Abuse (ISA; Hudson 1981).

Sexual abuse

Tiwari 2005 used a single question to ascertain if sexual abuse had occurred, while Gillum 2009 used individual items relating to sexual abuse from the PAS (Hudson 2006). Kiely 2010 and Tiwari 2010 opted for employing the sexual coercion subscale of the CTS2 (Straus 1996).

Emotional abuse

Investigators assessed emotional abuse using four measures. Two trials (McFarlane 2000; McFarlane 2006) employed the threats of abuse subscale of the SVAWS (Straus 1996) and two studies (Sullivan 1992; Tiwari 2005) used the Index of Psychological Abuse (IPA; Sullivan 1991). Gillum 2009 used the non-physical abuse subscale of the PAS (Hudson 2006), and Tiwari 2010 used the psychological aggression subscale of the CTS2 (Straus 1996).

Other aspects of abuse

McFarlane 2006 and Gillum 2009 also measured other aspects of abuse; both studies gauged homicide risk using the Danger Assessment Scale (DA Scale 2004), while McFarlane 2006 evaluated harassment at work using the Employment Harassment Scale (EHS 1992).

Investigators from three studies measured overall abuse using different methods. Hyman 2001 combined the physical and non-physical abuse subscales of the ISA (Hudson 1981), and Sullivan 2002 used a composite of a modified version of the IPA (Sullivan 2006) and the CTS physical violence subscale (Straus 1979). Taft 2011 assessed physical, sexual, and emotional abuse through the Composite Abuse Scale (CAS; Hegarty 2005).

Quality of life

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 (SF-12; Ware 1996), and Sullivan 1992 and Sullivan 2002 both used an adapted version of a scale by Andrews and Withey (Andrews 1976).

Depression

Taft 2011 and Tiwari 2005 both used the Edinburgh Postnatal Depression Scale (EPDS; Cox 1987). Tiwari 2010 utilised the Beck Depression Inventory II (BDI-II 1996), and Gillum 2009, Sullivan 1992, and Sullivan 2002 all measured depression using the Centre for Epidemiological Studies Depression Scale (CESD-R 2004).

Anxiety/psychological distress

Three studies measured anxiety/psychological distress: Hyman 2001 asked participants to complete the Symptoms Checklist 90-Revised (SCL-90-R 1994) in order to obtain the Global Severity Index score, Constantino 2005 asked participants to complete the Brief Symptom Inventory (BSI 1993), and Sullivan 1992 asked participants to complete the Rape Aftermath Symptom Test (RAST; Kilpatrick 1988).

Physical abuse

Eight studies measured physical abuse; six of these evaluated brief advocacy interventions (Gillum 2009; Kiely 2010; McFarlane 2000, McFarlane 2006, Tiwari 2005; Tiwari 2010), while the other two appraised intensive interventions (Sullivan 1991; Sullivan 1992). One study measured both severe and minor physical violence separately (Tiwari 2005); this study was also different from the others in that it assessed mean change from baseline. One of the studies employed a composite measure of physical and sexual abuse, but we were able to obtain separate data for each of these (Kiely 2010). We obtained additional statistical data from four study investigators (Gillum 2009; Kiely 2010; Sullivan 1992; Tiwari 2005).

We calculated effect sizes for five of the six studies that offered brief advocacy. As indicated (see Analysis 2.1 in ‘Data and analyses’), there was no evidence that advocacy leads to a reduction in physical abuse when this outcome is expressed using a continuous measure. Pooled data from three studies (n = 558)— two recruiting women in healthcare settings (Gillum 2009; McFarlane 2006) and the other from a community centre (Tiwari 2010)—showed no effect of advocacy in the short-term, that is, at up to 12 months follow-up (SMD 0.00, 95% CI – 0.17 to 0.16, I² = 0%; moderate quality evidence). Similarly, there was no effect in the medium term (SMD – 0.02, 95% CI – 0.24 to 0.19; n = 319) when McFarlane 2006 followed up women 24 months after the first intervention session (with sessions being provided thereafter every six months for up to two years). However, this pattern of results did not extend to Kiely 2010, the only trial that employed a dichotomous measure of physical abuse (Analysis 2.2). In this multi-component study, recruiting within an antenatal setting, women who received advocacy (and possibly also cognitive behavioural therapy (CBT), therapy for smoking/passive smoking, or both) were less likely to be experiencing physical abuse at the end of the intervention period (OR 0.42, 95% CI 0.23 to 0.75; n = 306). This means that one in every eight women that is given advocacy is likely to benefit from it (number needed to treat (NNT) = 8). Findings were more equivocal in the study that measured severe and minor abuse in pregnant women attending for antenatal care (Tiwari 2005). In this study, which had a low risk of bias, a brief 30-minute session of advocacy was not associated with any reduction in severe abuse as measured at 16 to 34 weeks postintervention (change-score MD 0.08, 95% CI – 0.26 to 0.42; n = 110; not statistically significant; moderate quality evidence), but investigators did observe a reduction in minor abuse (change-score MD – 1.00, 95% CI – 1.82 to – 0.18; n = 110; Analysis 2.3). The fifth trial that offered brief advocacy did not report any standard deviations, nor were these (or alternative relevant data) available from the authors (McFarlane 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 from antenatal clinics, either in the short or medium term.

Two studies, both recruiting women departing from domestic violence shelters, assessed the effectiveness of intensive advocacy. Sullivan 1992 measured physical abuse using both continuous and dichotomous measures, while Sullivan 1991 assessed this outcome using only a dichotomous measure. In the study that employed a continuous measure of physical abuse (Analysis 2.4), there was no evidence to confirm or refute the hypothesis that advocacy leads to a reduction in severe physical abuse at 12 months follow-up (MD – 0.12, 95% CI – 0.39 to 0.15; n = 265; low quality evidence) or at three years (MD 0.18, 95% CI – 0.20 to 0.56; n = 124). However, at the two-year follow-up, trialists reported that women who received advocacy experienced significantly less physical abuse than women in the control arm (MD – 0.25, 95% CI – 0.50 to 0.00; n = 265). A similar pattern of results also emerged with the dichotomous data (Analysis 2.5). Two studies contributed to a meta-analysis of the 12-month follow-up data (Sullivan 1991; Sullivan 1992); there was no evidence that advocacy reduced physical abuse (OR 0.61, 95% CI 0.33 to 1.14, I² = 0%; n = 182; very low quality evidence) with the NNT being eight women for one to benefit (Analysis 2.5). At later follow-up points, when data were only available for the Sullivan 1992 study, the findings suggest that participants who received advocacy experienced significantly less physical abuse than women in the control arm (OR 0.39, 95% CI 0.20 to 0.77; n = 265) at 12 to 24 months follow-up, again with 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).

Best case and worst case scenario analyses estimated the effects of missing data on the results of one meta-analysis (Analysis 2.6). For the 12-month follow-up data, the results did not change when imputing an improved outcome for intervention women who dropped out of the study (no control group women dropped out) (OR 0.54, 95% CI 0.29 to 1.01, I² = 0%; n = 192), or when imputing a poor outcome (OR 0.83, 95% CI 0.46 to 1.49, I² = 0%; n = 192).

For descriptive purposes only, two forest plots outline evidence for the effectiveness of any type of advocacy (brief or intensive) on physical abuse, as assessed using a continuous measure (Analysis 2.7) and a dichotomous measure (Analysis 2.8).

There is insufficient evidence at present to draw unequivocal conclusions about the benefits of advocacy, either within healthcare settings or within the community, for the reduction of severe physical abuse. One study with low risk of bias suggests that brief advocacy may benefit women suffering minor abuse, but most studies did not measure minor abuse. One further study evaluating brief advocacy within the context of a multi-component intervention showed a positive effect immediately upon completion, but there was no long-term follow-up, and it is not clear if the other components (in particular, CBT for depression) also had an impact. It is possible that intensive advocacy can reduce physical abuse one to two years after the intervention but that this effect wanes over time. The primary studies are underpowered (two of the eight trials were pilot studies), and we could only pool data from three brief interventions and two intensive interventions. The meta-analyses were still underpowered, with relatively wide CIs.

Sexual abuse

Three studies based in healthcare settings (Gillum 2009; Kiely 2010; Tiwari 2005) and one study within the community (Tiwari 2010) evaluated the effect of receiving brief advocacy on subsequent sexual abuse. (We obtained additional statistical data to those reported in the papers of Gillum 2009, Kiely 2010 and Tiwari 2010 directly from the study investigators). We conducted a meta-analysis on data from two of the studies (Gillum 2009; Tiwari 2010) and found that there was no statistically significant reduction in sexual abuse (SMD – 0.12, 95% CI – 0.37 to 0.14, I² = 44%; n = 239; moderate quality evidence) at up to 12 months (Analysis 1.1). Tiwari 2005 showed a reduction in sexual abuse in the months following receipt of advocacy, but the CIs included zero: change-score MD – 0.07, 95% CI – 0.30 to 0.16; n = 110; moderate quality evidence; Analysis 1.2). In the multi-component intervention study by Kiely 2010, there was no significant benefit associated with receiving advocacy—and possibly also CBT for depression or therapy for smoking/passive smoking (OR 0.96, 95% CI 0.44 to 2.12; n = 306; Analysis 1.3).

Emotional abuse

Six studies measured emotional abuse; five studies evaluated the effectiveness of brief advocacy (Gillum 2009; McFarlane 2000; McFarlane 2006; Tiwari 2005; Tiwari 2010), and a sixth study evaluated an intensive intervention (Sullivan 1992). Tiwari 2005 again measured mean change from baseline, and we obtained the additional statistical data that we required directly from the study investigators. We also obtained additional data from Gillum 2009.

We conducted a meta-analysis of data from three of the five studies that offered brief advocacy, two based in healthcare settings (Gillum 2009; McFarlane 2006) and one which was based within the community (Tiwari 2010). As shown in Analysis 3.1, the individual study results were inconsistent at up to 12 months follow-up, but the pooled point estimate indicates that there was no significant reduction in emotional abuse (SMD – 0.05, 95% CI – 0.22 to 0.11, I² = 51%; n = 558; low quality evidence) following the delivery of advocacy. McFarlane 2006 also followed up on participants 24 months after the first intervention session (with subsequent sessions being provided every six months); again there was no significant benefit associated with the receipt of advocacy (SMD – 0.06, 95% CI – 0.28 to 0.16; n = 319; Analysis 3.1). In contrast, the antenatal-based study by Tiwari 2005 reported a statistically significant reduction in emotional abuse at 16 to 34 weeks after receipt of a single, brief session of advocacy (change-score MD – 4.24, 95% CI – 6.42 to – 2.06; n = 110; moderate quality evidence; Analysis 3.2). The fifth trial did not report any standard deviations, nor were these (or alternative relevant data) available from the authors (McFarlane 2000). In the published 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 women recruited in an antenatal setting, in the short or medium term.

The one study that provided intensive advocacy to women leaving shelters, Sullivan 1992, did not show any significant reduction in emotional abuse at 12 months postintervention—either when this was assessed using a continuous measure (MD – 0.02, 95% CI – 0.16 to 0.12; n = 265; very low quality evidence; Analysis 3.3) or using a dichotomous measure (OR 0.58, 95% CI 0.30 to 1.13; n = 141; moderate quality evidence; Analysis 3.4). Similarly, there was no evidence of a reduction in emotional abuse as a result of receiving advocacy at 24 months follow-up (MD – 0.04, 95% CI –0.19 to 0.11; n = 265; Analysis 3.3).

A forest plot (Analysis 3.5) shows the effectiveness of any type of advocacy (brief or intensive) on emotional abuse, as expressed using a continuous measure.

With the exception of the two trials by Tiwari and colleagues, there is little evidence that advocacy reduces or leads to a cessation of emotional abuse. This conclusion holds for studies conducted both within and outside of healthcare settings and for studies offering either short or more intensive sessions of advocacy.

Financial abuse

No studies reported data for this outcome.

Other abuse measures

Quality of life

Six of the trials assessed quality of life. Three of the studies evaluated a brief advocacy intervention; one reported on the two summary component subscales (physical and mental) of the SF-12 Health Survey (Tiwari 2010), while the other two trials described mean changes from baseline for each of the eight subscales comprising the SF-36 measure of quality of life (Cripe 2010; Tiwari 2005). Of the three studies evaluating the effectiveness of intensive advocacy, one measured quality of life using the two summary component subscales (physical and mental) of the SF-36 (Taft 2011), and two measured overall quality of life (Sullivan 1992; Sullivan 2002). We obtained additional statistical data directly 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 significant benefit at six months follow-up either in terms of improved ‘physical’ quality of life (MD 0.80, 95% CI – 1.27 to 2.87; n = 200) or improved ‘mental’ quality of life (MD 0.37, 95% CI – 1.94 to 2.68; n = 200; Analysis 7.1). Similarly, upon pooling data from two studies (n = 314) that provided brief, one-off advocacy sessions to pregnant, abused women (Cripe 2010; Tiwari 2005), we found no significant improvements for any of the eight quality of life subscales at three to eight months postintervention: physical functioning (change-score MD 4.92, 95% CI – 0.32 to 10.16); role physical (change-score MD 7.42, 95% CI – 0.97 to 15.80); bodily pain (change score MD – 4.51, 95% CI – 10.42 to 1.39); general health (change-score MD – 0.85, 95% CI – 4.06 to 2.37); vitality (change-score MD – 1.38, 95% CI – 5.56 to 2.80), social functioning (change-score MD 0.92, 95% CI – 5.00 to 6.84); role emotional (change-score MD 9.37, 95% CI – 0.31 to 19.05); and mental health (change-score MD – 1.72, 95% CI – 5.31 to 1.87; Analysis 7.2). (N.B. We corrected for differences in the direction of the mean changes reported in the paper by Cripe 2010.)

Taft 2011 trained ‘mentor mothers' to provide up to 12 months intensive advocacy to abused women recruited within primary care clinics (although the intervention was administered in the community). This study had mixed results (Analysis 7.3): women who received advocacy reported significant improvements in their ‘physical’ quality of life immediately postintervention (MD 4.90, 95% CI 0.98 to 8.82; n = 103), but this did not extend to their perceived ‘mental’ quality of life (MD 1.90, 95% CI – 2.92 to 6.72; n = 103). Two of the studies conducted by Sullivan and colleagues (Sullivan 1992; Sullivan 2002) evaluated the effectiveness of advocacy delivered over a period of 10 to 16 weeks for women leaving domestic violence shelters or referred from social and family service agencies (Analysis 7.4). Both studies reported data at 12 months, and when pooled, data indicated a higher quality of life for women in the intervention group (MD 0.23, 95% CI 0.00 to 0.46; n = 343). Only one of these two studies followed up participants beyond 12 months (Sullivan 1992); data were obtained at two years postintervention and again at three years (but only for the original smaller sample of recruited women). There was no evidence that intensive advocacy improved quality of life at two (MD 0.25, 95% CI – 0.02 to 0.52; n = 265) or three years (MD 0.30, 95% CI – 0.07 to 0.67; n = 124). It is important to note that these findings differ from the significant effects reported by the study authors. We calculated mean differences based on the reported raw means and standard deviations, while the study authors reported findings based on multivariate analyses (two-year follow-up) and employed a P < 0.10 significance level to avoid type II errors as a result of the smaller sample size (three-year follow-up).

Analysis 7.5 presents a forest plot showing the effectiveness of any type of advocacy (brief or intensive) on ‘physical’ and ‘mental’ quality of life.

Overall, these studies suggest that brief advocacy is unlikely to improve quality of life in women who have experienced partner abuse.

Depression

Six studies assessed the effect of advocacy on depression: three evaluated the effect of a brief intervention (Gillum 2009; Tiwari 2005; Tiwari 2010), and three appraised the effect on an intensive intervention (Sullivan 1992; Sullivan 2002; Taft 2011). We obtained additional statistical data from four of the study investigators (Gillum 2009; Sullivan 1992; Taft 2011; Tiwari 2005). Gillum 2009 assessed depression using both continuous and dichotomous measures.

All three trials of brief advocacy followed women for less than 12 months postintervention. We pooled continuous data from two of the studies, one of which recruited women from a community centre (Tiwari 2010) and one from a primary care clinic (Gillum 2009). As indicated in Analysis 8.1, there was no evidence that women receiving advocacy reported lower levels of depression than women in the control group (SMD – 0.17, 95% CI –0.43 to 0.08, I² = 0%; n = 239). A meta-analysis of dichotomous data from Gillum 2009 and Tiwari 2005 (both in healthcare settings) showed that significantly fewer women developed depression (NNT = 4) if they received a brief advocacy intervention (OR 0.31, 95% CI 0.15 to 0.65, I² = 24%; n = 149; Analysis 8.2).

Of the three intensive advocacy studies, two recruited women exiting from domestic violence shelters (Sullivan 1992; Sullivan 2002) and one recruited women from primary care clinics (Taft 2011). All three trials assessed depression using a continuous measure at ≤ 12 months follow-up, and a meta-analysis of these data (Analysis 8.3) revealed no evidence that intensive adequacy reduces depression (SMD – 0.14, 95% CI – 0.33 to 0.05, I² = 27%; n = 446). In this meta-analysis, it should be highlighted that our calculated mean difference for Sullivan 2002 differs from the statistically significant effect reported by the study investigators, who conducted a multivariate analysis. Only one of these three intensive advocacy studies measured depression over a longer time period (Sullivan 1992); again, at two years follow-up, there was no evidence that receiving advocacy reduced depression among women in the intervention arm (SMD – 0.12, 95% CI – 0.36 to 0.12; n = 265; Analysis 8.3). Taft 2011 also assessed the effectiveness of intensive advocacy on depression immediately postintervention using a dichotomous measure (Analysis 8.4). The investigators reported no evidence to suggest that there were fewer cases of depression in the intervention group: OR 0.51, 95% CI 0.20 to 1.29; n = 103 (with an NNT of 8).

For descriptive purposes only, two forests plot outline the evidence for the effectiveness of any type of advocacy (brief or intensive) on depression, as measured using a continuous measure (Analysis 8.5) and a dichotomous measure (Analysis 8.6).

Overall, there is inconsistent evidence that advocacy has a beneficial impact on depression in abused women. There is limited evidence that brief advocacy delivered to abused women recruited within healthcare settings may help to reduce depression in the short-term.

Anxiety/psychological distress

One study measured anxiety as an outcome measure (Sullivan 1992), and two other studies measured psychological distress (Constantino 2005; Hyman 2001); as these are similar concepts, we discuss them together. Hyman 2001 appraised a brief advocacy intervention, while Constantino 2005 and Sullivan 1992 evaluated the effectiveness of intensive advocacy. We analysed Constantino 2005 separately, as it reported mean change from baseline. We obtained additional statistical data from authors of Hyman 2001 and Sullivan 1992.

For the brief intervention set in an accident and emergency department (Hyman 2001), there was significant evidence that advocacy reduced psychological distress at three to four months follow-up (MD – 0.56, 95% CI – 1.09 to – 0.03; n = 53; Analysis 9.1).

Both intensive interventions recruited women in domestic violence shelters, but we were unable to pool their findings because one reported mean change from baseline. As indicated in Analysis 9.2, Sullivan 1992 reported no statistically significant reduction of anxiety associated with the receipt of intensive advocacy at any time over the following three years: at 12 months (MD – 0.13, 95% CI – 0.35 to 0.09; n = 265), 24 months (MD – 0.01, 95% CI – 0.22 to 0.20; n = 265), or 36 months (MD – 0.11, 95% CI – 0.40 to 0.18; n = 124). In the one study that reported change-from-baseline data (Constantino 2005), the women were only followed up immediately postintervention. There was no evidence that advocacy decreased psychological distress (change-score MD – 35.41, 95% CI – 75.98 to 5.16; n = 24; Analysis 9.3). (N.B. In the Constantino trial, the authors reported a statistically significant effect (P value = 0.013) after using a non-parametric test to analyse the change from baseline data.)

Analysis 9.4 presents a forest plot showing the effectiveness of any type of advocacy (brief or intensive) on anxiety/psychological distress.

These studies suggest that brief advocacy offered within healthcare settings may reduce abused women's feelings of anxiety and psychological distress in the short-term, but it is unknown whether such a benefit would persist over time. The benefits of offering intensive advocacy to abused women in the community are unclear at present.

Death

Two participants died before completion of the studies into which they were recruited. In McFarlane 2000, which recruited women seeking protection orders, one woman in the control group committed suicide three weeks into the trial. In Sullivan 1992, which recruited women in domestic violence shelters, one woman in the intervention arm was murdered by her partner two weeks into the trial.

Chronic health disorders

Gillum 2009 measured chronic pain and fatigue; over a three-month period, it provided multiple sessions of brief advocacy to abused women recruited in a healthcare setting. The study authors supplied all data relating to these outcomes. When followed up immediately postintervention, there was no evidence that women who received advocacy reported less chronic pain (MD – 10.50, 95% CI – 26.78 to 5.78; n = 39; Analysis 10.1) or chronic fatigue (MD – 10.50, 95% CI – 26.81 to 5.81; n = 39; Analysis 11.1) than women in the control arm.

Birth outcomes

Kiely 2010 measured birth outcomes following a brief multi-component intervention delivered to pregnant women (advocacy for abuse and, depending on risk, CBT therapy for depression and therapy for smoking or passive smoking cessation/reduction). It is important to note that for the ORs given below, our calculated percentages differ slightly from those reported in the paper. As indicated in Analysis 12.1, there was no evidence to suggest that women who received the intervention were less likely to deliver underweight babies as compared with women in the control group (babies weighing less than 2500 g, n = 306, OR 0.70, 95% CI 0.36 to 1.37; and babies weighing less than 1500 g, n = 306, OR 0.17, 95% CI 0.02 to 1.41). Similarly, there was no difference between groups in terms of actual birthweight (MD 41.00, 95% CI – 106.19 to 188.19; n = 306; Analysis 13.1), and there was no evidence to suggest that fewer women who received the intervention had premature births (babies born at 37 weeks gestation: OR 0.65, 95% CI 0.34 to 1.24; n = 306; babies born less than 33 weeks gestation: OR 0.22, 95% CI 0.05 to 1.04; n = 306; Analysis 14.1); this latter result differs from the significant effect (P value = 0.03) reported in the paper. Actual gestational age at delivery did significantly differ between women in the two arms of the study, 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 of physical health.

Post-traumatic stress

Women who received advocacy in two trials (Gillum 2009; Hyman 2001) did not significantly differ from women in the control groups in relation to levels of posttraumatic stress (SMD – 0.21, 95% CI – 0.62 to 0.21, I² = 38%; n = 92; Analysis 16.1), according to data provided by the study investigators.

Perceived stress

Data provided by the authors of Hyman 2001 suggests that women who received advocacy had significantly lower levels of perceived stress compared with women in the control condition (MD – 0.56, 95% CI – 1.09 to – 0.03; n = 53; Analysis 17.1).

Self efficacy

Sullivan 1992 measured self efficacy after intensive advocacy in women exiting domestic violence shelters. We obtained additional statistical data relating to this outcome from the study investigators. At no time point was there evidence that women who received advocacy reported higher levels of self efficacy than women in the control arm. The effect sizes were MD 0.08, 95% CI – 0.19 to 0.35; n = 265 at 12 months follow-up; MD 0.16, 95% CI –0.10 to 0.42; n = 265 at two years follow-up; and MD 0.14, 95% CI – 0.22 to 0.50; n = 124 at three years follow-up (Analysis 18.1).

Self esteem

Sullivan 2002 reported an improvement in self esteem following advocacy (using a multivariate analysis), although our calculated effect size shows that this was statistically non-significant (MD 0.26, 95% CI – 0.03 to 0.55; n = 78; Analysis 19.1). These data came from the study investigator.

Perceived social support

Five of the studies assessed social support: one of these investigated the effect of brief advocacy for abused women recruited at 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 social and family service agencies (Constantino 2005; Sullivan 1992; Sullivan 2002), or attending primary care clinics (Taft 2011). All of these studies assessed social support using an overall measure, but one trial also assessed four separate components of social support (Constantino 2005). This study was also different from the others in that the authors assessed mean change from baseline. We obtained additional statistical data from authors of all four intensive advocacy studies.

There was no evidence that abused women receiving brief advocacy in Tiwari 2010 reported higher levels of social support at six months follow-up compared with women in the control arm (MD 1.60, 95% CI – 0.37 to 3.57; n = 200; Analysis 20.1). It is important to note that this calculated effect size differs from the statistically significant finding (P value = 0.01) reported by the study authors, who adjusted for baseline differences.

Three of the intensive advocacy trials reported data from the 12-month follow-up that could be pooled (Sullivan 1992; Sullivan 2002; Taft 2011). As indicated in the forest plot (Analysis 20.2), there was no evidence to suggest that advocacy had a positive effect on social support in the short-term (SMD 0.00, 95% CI – 0.19 to 0.19, I² = 16%; n = 446). Further follow-up data were only available from one of these studies (Sullivan 1992). There was no evidence that advocacy improved social support at two years (SMD 0.12, 95% CI – 0.12 to 0.37; n = 265), but by three years (based on the smaller original sample recruited in to the study), there was a clear and significant beneficial effect on social support outcomes (SMD 0.39, 95% CI 0.03 to 0.74; n = 124). Constantino 2005 (n = 24) reported finding no effect on overall social support following advocacy (using a non-parametric test), but our analysis (Analysis 20.3) indicates that there was a positive effect (change-score MD 10.19, 95% CI 5.67 to 14.71) when the women were followed up immediately postintervention. Similarly, while the authors reported an improvement only on the ‘belonging’ subscale, our analysis showed significant effects for all four subscales: ‘tangible’ (change-score MD 2.19, 95% CI 0.93 to 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).

For descriptive purposes only, Analysis 20.4 presents a forest plot showing the effectiveness of any type of advocacy (brief or intensive) on social support.

There are insufficient studies to draw a conclusion about the benefits of brief advocacy. For intensive advocacy, there is inconsistent evidence that such an intervention improves social support in the short term. In the long term, intensive advocacy may produce a positive effect, but this is based on the findings of one small study in women who actively sought help.

Impact on relationships

Use of safety behaviours

Four trials investigated the use of safety behaviours. All studied brief interventions, and three recruited within a healthcare setting (Cripe 2010; Gillum 2009; McFarlane 2006) while one recruited within the community (Tiwari 2010). Two of the trials reported (McFarlane 2006; Tiwari 2010) or provided on request (Gillum 2009) usable follow-up data. As indicated in Analysis 23.1, pooled data from these three studies at < 12 months follow-up showed that abused women who received advocacy employed a significantly higher number of safety behaviours compared with women receiving usual care (MD 1.39, 95% CI 0.92 to 1.87, I² = 97%; n = 558). However, this benefit was not apparent in McFarlane 2006, the one trial with a two-year follow-up (MD 0.10, 95% CI – 0.42 to 0.62; n = 319). We were not able to obtain any usable data for the Cripe 2010 study. The paper reports that when women were followed up 14 to 28 weeks postintervention, there was an increase in the number of women in the intervention group who adopted 8 of the 13 safety behaviours (range 1.8% to 30.3%); this contrasts with a smaller increase of women in the control group who adopted four of the safety behaviours (range 0.5% to 11.2%). However, there were no statistically significant differences between the two trial arms for any of the 13 safety behaviours investigated.

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