The World Health Organisation estimates that between 10% and 50% of women worldwide report having been assaulted physically or sexually by an intimate partner at some time in their lives, and when threats, financial and emotional abuse are included the prevalence rates are even higher. Abused women can suffer injury and long-lasting physical and emotional health problems. One form of intervention to assist these women is advocacy. Advocacy interventions aim to help abused women directly by providing them with information and support to facilitate access to community resources. However, before recommending them to health policy makers we need to know whether they improve the health and well-being of abused women. In other words, are advocacy interventions effective?
After searching the world literature for randomised controlled trials evaluating advocacy programmes for abused women, we found ten trials, involving 1,527 women. The studies comparing advocacy with "usual care" were conducted in a variety of settings both within and outside of healthcare. Participants were recruited from diverse ethnic populations and across a wide age range (15-61 years), but many had a relatively deprived socioeconomic status. Most were experiencing current, often severe, abuse. All of the interventions sought to empower the women by helping them to achieve their goals. They differed in: duration (from 30 minutes to 80 hours), the outcomes reported, and the length of time the women were followed up.
The evidence is consistent with intensive advocacy decreasing physical abuse more than one to two years after the intervention for women already in refuges, but there is inconsistent evidence for a positive impact on emotional abuse. Similarly, there is equivocal evidence for the positive effects of intensive advocacy on depression, quality of life and psychological distress. There is evidence that brief advocacy increases the use of safety behaviours by abused women.
Taken as a whole, we conclude that at present there is equivocal evidence to determine whether intensive advocacy for women recruited in domestic violence shelters or refuges has a beneficial effect on their physical and psychosocial well-being. Further, we do not know if less intensive interventions in healthcare settings are effective for women who still live with abusive partners. Too few studies evaluated interventions of comparable intensity and duration, measured the same outcomes, or had comparable follow-up periods.
Based on the evidence reviewed, it is possible that intensive advocacy for women recruited in domestic violence shelters or refuges reduces physical abuse one to two years after the intervention but we do not know if it has a beneficial effect on their quality of life and mental health. Similarly, there is insufficient evidence to show if less intensive interventions in healthcare settings for women who still live with the perpetrators of violence are effective.
Intimate partner abuse is common in all societies and damages the health of survivors and their children in the short and long term. Advocacy may decrease the impact of this abuse on women's health.
To assess the effects of advocacy interventions conducted within or outside of health care settings on women who have experienced intimate partner abuse.
We searched: CENTRAL and DARE (Cochrane Library Issue 3, 2008), MEDLINE (1966 to 31/7/08), EMBASE (1980 to 2008 week 30), and 11 other databases, to end July 2008. We also searched relevant websites, reference lists and forward citation tracking of included studies, and handsearched six key journals. We contacted principal investigators and experts in the field.
Randomised controlled trials comparing advocacy interventions for women with experience of intimate partner abuse against usual care.
Two reviewers independently assessed trial quality and undertook data extraction. For binary outcomes we calculated a standardised estimation of the odds ratio (OR) and for continuous data we calculated either a standardised mean difference (SMD) or a weighted mean difference (WMD), both with a 95% confidence interval.
We included ten trials involving 1527 participants. The studies were heterogeneous in respect of: intensity of advocacy, outcome measures and duration of follow-up (immediately post-intervention to three years), permitting meta-analysis for only a minority of outcomes. Intensive advocacy (12 hours or more duration) may help terminate physical abuse in women leaving domestic violence shelters or refuges at 12-24 months follow-up (OR 0.43, 95% CI 0.23 to 0.80), but not at up to 12 months follow-up. The evidence indicates that intensive advocacy may improve quality of life at up to 12 months follow-up, but the confidence intervals included zero (WMD 0.23, 95% CI 0.00 to 0.46). Depression did not improve following intensive advocacy at up to 12 months follow-up (WMD -0.05, 95% CI -0.19 to 0.09), nor did psychological distress (SMD -0.16, 95% CI -0.39 to 0.06). Only two meta-analyses of brief advocacy interventions (less than 12 hours duration) were possible; an increased use of safety behaviours was consistent with the receipt of brief advocacy both at up to 12 months (WMD 0.60, 95% CI 0.14 to 1.06) and at 12-24 months (WMD 0.48, 95% CI 0.04 to 0.92) follow up.