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Cited by 65Intimate Partner and Family ViolenceElder Abuse and NeglectSexual Assault and Victimization Studies

A realist review of which advocacy interventions work for which abused women under what circumstances

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Rivas, Carol, Vigurs, Carol, Cameron, Jacqui, Yeo, Lucia·2019·Cochrane Database of Systematic Reviews
DOI 10.1002/14651858.cd013135.pub2PMC PMC6598804
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Abstract

BACKGROUND: Intimate partner abuse (including coercive control, physical, sexual, economic, emotional and economic abuse) is common worldwide. Advocacy may help women who are in, or have left, an abusive intimate relationship, to stop or reduce repeat victimisation and overcome consequences of the abuse. Advocacy primarily involves education, safety planning support and increasing access to different services. It may be stand-alone or part of other services and interventions, and may be provided within healthcare, criminal justice, social, government or specialist domestic violence services. We focus on the abuse of women, as interventions for abused men require different considerations. OBJECTIVES: To assess advocacy interventions for intimate partner abuse in women, in terms of which interventions work for whom, why and in what circumstances. SEARCH METHODS: In January 2019 we searched CENTRAL, MEDLINE, 12 other databases, two trials registers and two relevant websites. The search had three phases: scoping of articles to identify candidate theories; iterative recursive search for studies to explore and fill gaps in these theories; and systematic search for studies to test, confirm or refute our explanatory theory. SELECTION CRITERIA: Empirical studies of any advocacy or multi-component intervention including advocacy, intended for women aged 15 years and over who were experiencing or had experienced any form of intimate partner abuse, or of advocates delivering such interventions, or experiences of women who were receiving or had received such an intervention. Partner abuse encompasses coercive control in the absence of physical abuse. For theory development, we included studies that did not strictly fit our original criteria but provided information useful for theory development. DATA COLLECTION AND ANALYSIS: Four review authors independently extracted data, with double assessment of 10% of the data, and assessed risk of bias and quality of the evidence. We adopted RAMESES (Realist and meta-narrative evidence syntheses: evolving standards) standards for reporting results. We applied a realist approach to the analysis. MAIN RESULTS: We included 98 studies (147 articles). There were 88 core studies: 37 focused on advocates (4 survey-based, 3 instrument development, 30 qualitative focus) and seven on abused women (6 qualitative studies, 1 survey); 44 were experimental intervention studies (some including qualitative evaluations). Ten further studies (3 randomised controlled trials (RCTs), 1 intervention process evaluation, 1 qualitative study, 2 mixed methods studies, 2 surveys of women, and 1 mixed methods study of women and staff) did not fit the original criteria but added useful information, as befitting a realist approach. Two studies are awaiting classification and three are ongoing.Advocacy interventions varied considerably in contact hours, profession delivering and setting.We constructed a conceptual model from six essential principles based on context-mechanism-outcome (CMO) patterns.We have moderate and high confidence in evidence for the importance of considering both women's vulnerabilities and intersectionalities and the trade-offs of abuse-related decisions in the contexts of individual women's lives. Decisions should consider the risks to the woman's safety from the abuse. Whether actions resulting from advocacy increase or decrease abuse depends on contextual factors (e.g. severity and type of abuse), and the outcomes the particular advocacy intervention is designed to address (e.g. increasing successful court orders versus decreasing depression).We have low confidence in evidence regarding the significance of physical dependencies, being pregnant or having children. There were links between setting (high confidence), and potentially also theoretical underpinnings of interventions, type, duration and intensity of advocacy, advocate discipline and outcomes (moderate and low confidence). A good therapeutic alliance was important (high confidence); this alliance might be improved when advocates are matched with abused women on ethnicity or abuse experience, exercise cultural humility, and remove structural barriers to resource access by marginalised women. We identified significant challenges for advocates in inter-organisational working, vicarious traumatisation, and lack of clarity on how much support to give a woman (moderate and high confidence). To work effectively, advocates need ongoing training, role clarity, access to resources, and peer and institutional support.Our provisional model highlights the complex way that factors combine and interact for effective advocacy. We confirmed the core ingredients of advocacy according to both women and advocates, supported by studies and theoretical considerations: education and information on abuse; rights and resources; active referral and liaising with other services; risk assessment and safety planning. We were unable to confirm the impact of

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  • Relatively few interventions have been shown to improve the safety, health or quality of life of women experiencing IPV.

    “Relatively few interventions have been shown to improve the safety, health or quality of life of women experiencing IPV”

    From Longitudinal impacts of an online safety and health intervention for women experiencing intimate partner violence: randomized controlled trial (2020) · cites this paper as [15]

    The Results (page not available) report mixed outcomes for advocacy interventions, including some improvements in safety and quality of life and other studies finding no benefit. This supports the claim's concern about limited demonstrated benefits for advocacy, but the review does not establish that relatively few interventions of all kinds improve safety, health or quality of life for women experiencing IPV. (LLM, conf=0.78)

    Experimental — accuracy not yet measured

  • Some types of face-to-face interventions, including advocacy and cognitive behavioural therapy, are effective with some populations and/or under certain conditions.

    “although there is growing evidence that some types of face-to-face interventions, including advocacy and cognitive behavioural therapy, are effective with some populations and/or under certain conditions [15–17].”

    From Longitudinal impacts of an online safety and health intervention for women experiencing intimate partner violence: randomized controlled trial (2020) · cites this paper as [15]

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  1. Data synthesis across stages and across these three approaches drew on: juxtaposition of sources in ways that might have provided further insights; consolidation of sources when evidence about mechanisms and outcomes was complementary; reconciliation of sources where outcomes differed in comparable context; situation of sources where outcomes differed in different contexts; and adjudication of sources according to methodological strengths or weaknesses (Gough 2007; Pearson 2015; see also 'Strength and quality of the evidence' section below).
  2. The review authors independently assessed the extent to which each study attempted to control for six potential types of bias and assigned ratings of 'low risk of bias', 'high risk of bias', or 'unclear risk of bias' accordingly. We used the 2011 Cochrane 'Risk of bias' criteria (Higgins 2011), rather than the recently updated version (Higgins 2019), since the earlier version allowed for different trial designs. We considered the following criteria.
  3. Adequacy of the data contributing to a review finding: an overall determination of the degree of richness and quantity of data supporting a review finding. We used the concept of 'thickness' of the sources (Roen 2006), that is, the degree to which they offered explanatory insights on the developing theory and the factors shaping implementation processes. The criteria we used to assess thickness were: detail of the description of relevance to our emerging theory; level of consideration of the relevant context and its influence; detail on potential mediators or moderators; and attempt to explain anomalous results and findings with reference to context and to data.
  4. Changes from the protocol for this review (Rivas 2018) are shown in Table 1.
  5. The phase 2 electronic database search and initial handsearching yielded a total of 6165 unique articles, which we entered into EPPI‐4 review management software (Thomas 2010). After screening article titles and abstracts against the pre‐specified inclusion and exclusion criteria, we identified 153 potentially relevant articles. Following discussion we decided not to include advocacy for conditions or situations other than intimate partner abuse at this stage. So we screened the titles and abstracts of these 153 articles for a second time, reducing them to 83 potentially eligible articles. We retrieved the full‐text copies of these 83 papers and two review authors independently assessed them for relevance, resolving disagreements through discussion; we did not need arbitration with a third review author. This resulted in a total of 31 included articles added to the 81 in phase 1. We identified 152 additional papers using CLUSTER in phase 2, of which we included 16. Iterative searching as we developed our theory resulted in a further 16 included articles from 117 considered. By the end of phase 2 we had found 144 relevant articles (including the phase 1 articles) and identified two studies that are awaiting assessment and three ongoing studies.
  6. Five of the 37 studies used a qualitative focus group or group interview approach. In Goodman 2016b, 38 advocates working in a range of intimate partner abuse programmes across one state in the USA were asked about their use and perceptions of network‐oriented strategies. Lynch 2013 conducted focus groups with 24 participants from organisations including women's refuges, family support services, domestic violence outreach services, solicitors, and Domestic Court Advocacy Services (DVCAS); the commonality was that all had assisted women seeking Apprehended Domestic Violence Orders (ADVOs) in New South Wales, Australia. Logan 2018 ran five focus groups with 37 domestic violence and sexual assault advocates from a variety of settings in the USA to explore safety planning strategies. They reported analyses across two companion papers. Similarly, and also in the USA, Murray 2015 explored 62 domestic violence service providers' perspectives toward safety planning. In a very different setting, Infanti 2015 undertook group interviews and ran a participatory workshop with 31 public‐health midwife advocates working on the tea estates of Sri Lanka.
  7. Nine studies used a mixture of interviews and other forms of data collection. Briones‐Vozmediano 2014 undertook 29 interviews and four focus groups with 43 professionals (social workers, psychologists, intercultural mediators, judges, lawyers, and public health professionals) who were involved in providing support for battered immigrant women in Spain. Ganz 2015 used cultural studies, feminist methodology and sociological theory to analyse 21 interviews with advocates plus a survey begun by 382 advocates with a completion rate of 221/382 (58%). Kapur 2017 recruited 26 domestic violence advocates from 14 South Asian‐focused non‐profit organisations in the USA (10 providing direct services to women and four acting as legal or advocacy organisations), to explore how they managed the domestic violence‐related intersectional needs of Asian‐Indian marriage migrants. Sixteen advocates were interviewed face‐to‐face and five were interviewed by phone; five more attended a group interview. Kolb 2008 undertook non‐participant ethnography at an organisation in the USA called SAFE (Stopping Abuse in Family Environments), and interviews with one of the agency's co‐directors, four advocates, five counsellors and two full‐time shelter staff, between July 2005 to August 2006. The shelter director and a family counsellor worked in a shelter, the co‐director worked in a small office in the next town and the others all worked at the main agency office. Reina 2015, also in the USA, completed individual, semi‐structured interviews and a focus group with 10 undocumented Latinas recruited from a non‐profit domestic violence and sexual assault agency. In the UK, Lea 2016 undertook case‐file analysis (n = 86) of an existing, independent domestic abuse service known as the Domestic Abuse Advocacy Project (DAAP), and interviews with abused women (n = 12) and key individuals based in related statutory and community organisations (n = 12). DAAP included free specialist legal advice and support with civil action, as well as other advocacy work to facilitate access to a range of social and health‐related specialist services. The advocate was a specialist family law solicitor trained in intimate partner abuse advocacy. The evaluation of DAAP was independent and participatory, involving intervention stakeholders, and was aimed at informing strategic decision‐making by the local multi‐agency domestic abuse partnership board. Wies 2008 focused her research on two domestic violence shelters in Kentucky, USA. She used participant observation, working as an advocate to observe other advocates in‐role. She also ran four focus groups with the advocates, and collected documentary information from archives, popular media sources. newsletters, regional reports, conference materials and internal paperwork. In addition, she interviewed individuals who self‐identified as participants in the Kentucky domestic violence social movement in the past. Burnett 2012 undertook in‐depth interviews and focus groups with 37 staff and four executive directors from four shelters in Ontario, Canada, as well as analysing relevant policy documents using critical discourse analysis. Johnson 2014 undertook telephone interviews with 25 intimate partner abuse advocates (67.5% of those invited to take part) who worked at 20 of the 28 advocacy locations (71.4% sampled) across 16 rural counties in the USA; six advocates also attended a focus group. Johnson 2014 explored the microsystem and exosystem levels of the ecological model to understand advocates' relationships with abused women and criminal justice personnel.
  8. Three studies differed from the rest in that they focused on instrument‐development using an exploratory, sequential mixed‐methods design. The PhD dissertation by Magruder 2017 described the development of the Intimate Partner Violence Responder Collaboration Scale. The qualitative component of this study, semi‐structured interviews with 15 intimate partner abuse service delivery staff (victim advocates/victim service providers, law enforcement professionals, prosecutors, and perpetrator intervention providers) in Florida, provided valuable information on what intimate partner abuse responders consider to be important elements of collaboration between organisations. The primary focus of the survey‐based study by Kulkarni 2015 was the development and revision of the Survivor‐Defined Advocacy Scale (SDAS), to assesses intimate partner abuse service providers' attitudes about their work and clients. In developing this scale, Kulkarni 2015 were able to report on critical mediating variables, but it should be noted that participants represented a range of intimate partner abuse service roles, including advocates or case managers, counsellors and administrators (shelter personnel and outreach or educators). Goodman 2016a surveyed a convenience sample of 370 abused women seeking services at one of 15 urban and suburban intimate partner abuse organisations in five states in the USA about the strength of their alliance with their advocates, and symptoms of depression and post‐traumatic stress disorder (PTSD). All the programmes in the Goodman 2016a study provided safety planning, counselling, and referral services for abused women. Furthermore, most provided emergency shelter, with stay lengths of several weeks to six months, and several also offered transitional living programmes, with stay lengths of up to two years. In a separate paper as part of the Goodman 2016a study, the authors built on these findings, developing the Survivor‐Defined Practice Scale from the perspective of abused women. They used factor analysis to determine the core elements of safety‐related empowerment and the link between survivor‐defined practice and safety‐related empowerment to be incorporated into the scale. The result was a nine‐item measure that assessed participants' perception of the degree to which their advocates helped them achieve goals they set for themselves, facilitated a spirit of partnership, and showed sensitivity to their individual needs and styles. The study authors also developed a final, 13‐item validated measure, the Measure of Victim Empowerment Related to Safety (MOVERS), from triangulation with other data collected as part of the same broad programme of work. In a third paper, Goodman 2016a and colleagues analysed the quantitative survey data used for the safety subscale of MOVERS and also the associated qualitative free‐text answers using content analysis. Most of the analysis in this paper involved the full survey sample but they gave only 215 respondents three questions on retrospective evaluation, and of these, 117 responded; thus, the consideration of whether women would have done things differently in retrospect drew on a smaller subset than other considerations in this paper.
  9. Among the studies we included in this review, only six were qualitative studies of women that were not associated with (and therefore reported under) intervention studies. Two also included agency staff (Gillum 2008; Weisz 1999). Bader 2014 undertook 26 interviews with women who disclosed to service providers that they were experiencing intimate partner abuse, as part of a co‐ordinated community response in Canada. Ekstrom 2015 interviewed a convenience sample of six abused women who had all received social support and advice about police investigations and criminal trials concerning the perpetrator from the Relationship Violence Centre (RVC) in Stockholm. The social workers from the RVC were employed by social services, but the RVC was located at the regional police office and co‐operated closely with social services, the police, and to some extent, also prosecutors. Gillum 2008 held two focus groups with 11 African‐American abused women, two interviews with two further African‐American abused women, and a separate interview involving two African‐American female service providers who worked primarily with African‐American abused women. In a separate analysis as part of the same overall programme of work, Gillum 2008 interviewed 13 abused women for a service user perspective of a domestic violence agency in the USA, the co‐ordinator of Victim's Services for an administrative perspective, and two of the agency's advocates for a direct service provider perspective. Hathaway 2008 used structured interviews to explore abused women's perceptions of an existing, long‐term intimate partner abuse advocacy programme involving five professional advocates and based in the social service department of a large, urban teaching hospital. Advocacy was flexible, survivor‐focused and on‐demand, and included crisis intervention, risk assessment and safety planning, individual counselling and support groups, assistance connecting to resources, and accompaniment to key appointments. Kenyon 2016 undertook and analysed nine interviews with abused women in shelters in Canada, using the Fraser 2004 narrative method, which situates personal stories within their social context. Weisz 1999 used open‐ended interviews and focus groups to explore advocates and abused women's views and experiences of legal advocacy in the USA.
  10. Using a single‐group pre‐post design, Bacchus 2007 evaluated a domestic violence intervention in the maternity and sexual health services department of a UK hospital, which included referral of women disclosing violence to an on‐site advocacy service (MOZAIC Women's Well Being Project, provided by a community organisation). They conducted semi‐structured interviews with 34 women, one to 22 months after they received support from the service, selected according to clinical setting, living with abuser or not at the time of referral advocacy, length of abuse, pregnant or not, immigration status, access to their own money, ethnic origin and first language (English or Spanish). Three hospital staff who used the advocacy service were amongst those interviewed. They also undertook semi‐structured interviews with staff (8 midwives and 11 sexual health professionals), as well as six focus group discussions (19 midwives and 6 sexual health professionals); they selected participants according to clinical setting (maternity or sexual health), professional group (doctors, nurses, midwives, health advisors), gender, and time elapsed since training (three months versus more than six months). They reviewed maternity records for 487 (98%) of the 501 women who gave birth in January 2007. A total of 915 women attended the sexual health clinic in a one‐month assessment period. However, of the 879 records available for audit, they analysed only the 644 (73%) records that contained the domestic violence code. Kendall 2009, in a hospital emergency department pre‐post study, gave a convenience sample of 350 women an initial session of their advocacy intervention (Domestic Violence Healthcare Project; DVHP) face‐to‐face, with follow‐on telephone contact to see whether women were keeping to their plans at 2, 6, and 12 weeks; they also collected outcomes data during these calls. Part way through the study, they added another phone on day two, to increase retention. In a pre‐post study, Tutty 1996 evaluated two programmes in which 31 women departing a battered women's shelter received three to six months of “advocacy and counselling” from a bachelor's‐level social worker. Wuest 2015 carried out a feasibility study of a health intervention for abused women. They detailed the intervention development in two separate papers. One described initial qualitative interviews with purposeful samples of women and community stakeholders, and focus groups with nurse home visitors recruited from four sites. They based development of the IPV intervention, which is described in depth in the second development paper, on data from 69 respondents. The study itself as undertaken by Wuest 2015, was conducted in partnership with policy, community and practitioner stakeholders. The study used a mixed‐methods design, combining a single‐group, pre‐post intervention study with 52 survivors of IPV, of whom 42 completed data collection, with chart review data and interviews of 18 purposefully sampled participants and all nine interventionists. Krasnoff 2002 reported on an observational case study of an IPV advocacy intervention provided on‐site at an urban hospital emergency department with screening for IPV by a nurse, a session with a volunteer advocate from a local human service agency crisis intervention when IPV was identified (given within 30 minutes of screening) and referral to telephone‐based follow‐up care from a professional case manager. Of the 528 women identified as experiencing IPV, 475 (84%) agreed to speak to the advocate, and 258 (54% of those seen by the advocate) accepted case management lasting 3 to 6 weeks. Pre‐post measures were reported.
  11. In a cluster‐RCT, Gupta 2017 randomised 42 public health clinics in Mexico City to intervention or control arms. The intervention group (n = 470 women) received a nurse‐delivered session of IPV screening, supportive referrals and health/safety risk assessments, and enhanced nurse‐delivered advocacy if needed. A booster session was given after three months. The aim was to reduce IPV and reproductive coercion, and improve levels of safety planning behaviours, use of community resources and mental well‐being. Control clinics offered women (n = 480) screening for IPV and a referral card. Follow‐up was post‐intervention and at three and 15 months from baseline. Kiely 2010 recruited 1044 women to an RCT comparing the intervention (n = 521) to usual care (n = 523). The intervention provided advocacy within the context of two 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/passive smoking sessions if smoking or environmental tobacco smoke exposure were identified risks. A subset of 336 women were abused at baseline (169 intervention group, 167 control group). There was no follow‐up after completion of the intervention. In a multi‐centre RCT described over three papers, including the protocol, Lako 2018 compared Critical Time Intervention (CTI), a time‐limited (nine‐month) outreach intervention, to care‐as‐usual for abused women making the transition from shelter facilities to supported or independent housing. Participants were recruited from 19 women's shelters in the Netherlands, with questionnaires administered before leaving the shelter and at follow‐up at three, six and nine months after leaving the shelter (that is, at end of the intervention). Altogether 136 women were assigned to CTI (n = 70) or care‐as‐usual (n = 66). In one of the two analysis papers, Lako 2018 used intention‐to‐treat, three‐level, mixed‐effects models. The second paper for the same study (Lako 2018), explored fidelity and factors influencing adherence, from chart review (n = 70) and two focus groups with CTI workers (n = 11). McFarlane 2004 evaluated a telephone intervention intended to increase the safety‐promoting behaviours of abused women, with a total of 54 minutes of advocacy being given (six, nine‐minute telephone calls) over eight weeks, as well as usual services of the District Attorney's office. This RCT, randomised 75 women to the intervention and 75 to usual care (usual services of the District Attorney's office), with follow‐up calls to assess safety‐ promoting behaviours at 3, 6, 12, and 18 months. McFarlane 2006 completed a two‐arm RCT in urban public primary care clinics with 360 abused women who had experienced physical or sexual abuse within the preceding 12 months. The study tested two interventions: a wallet‐sized referral card and a 20‐minute nurse case‐management protocol, with follow‐up to 24 months. Rodgers 2017 assessed the feasibility, acceptability, and safety of Community Health Worker (CHW) outreach co‐ordinated with enhanced clinic‐based IPV advocacy services from a Family Health Advocate (FHA) trained in IPV advocacy and motivational interviewing. The setting for this RCT was four urban community health clinics. Women were randomised to either the FHA plus CHW intervention (n = 10) or the clinic‐based FHA intervention alone (n = 9). As this was a feasibility and acceptability study, Rodgers 2017 do not report clinical outcomes but the experiences and needs of the abused women, drawing on the CHW's field notes and structured interviews with the 10 women in the intervention group.
  12. Bybee 2005 undertook longitudinal evaluation of women who were leaving a domestic violence shelter after at least one night's stay and were randomly assigned 1:1 to usual care or to four to six hours per week of one‐on‐one advocacy for 10 weeks. Trained undergraduates undertook advocacy and the focus was on assisting women in accessing needed community resources. Follow‐up was immediately upon exit, and at 10 weeks and 6, 12, 18, and 24 months post‐intervention and at 36 months (considered in different papers). The initial sample was 141 women with further data collection resulting in a total sample of 278 women interviewed every six months for two years and a subset of 124 women re‐interviewed at three years. A mediation analysis of the data was reported in one of the six papers on the study included in this review. Sullivan 1991 also studied a more intensive advocacy programme in which services were provided by “trained paraprofessionals” for six to eight hours per week over 16 weeks. In a similar study, Sullivan 2002 recruited abused mothers with at least one child from a mid‐sized urban city, either after they had exited a domestic violence shelter programme (79%) or when they obtained services from a community‐based family service organisation (4%) or a state Social Services department (18%) (figures taken directly from the report). Mothers randomised to the intervention group (n = 80) received the free services of a trained paraprofessional for six to eight hours per week over 16 weeks for IPV advocacy, with an additional 10‐week support and education group for the children. They did not specify the control group intervention. Follow‐up was to four months after the end of the intervention.
  13. Constantino 2005 is one of the additional 10 studies thus included. It was a core paper in Rivas 2015 but in this realist review, we did not treat studies of group‐based advocacy as core, since group work depends on a specific range of behaviour‐change techniques (Michie 2013). Constantino 2005 undertook an RCT to evaluate the feasibility and effectiveness of a group intervention that allowed for interaction between women, as well as interaction between the women and the advocate. The study authors labelled this a "social support intervention". Given to 24 women in a shelter in the USA, it focused on accessing community resources, including information on resources and hours of operation for those resources when available. There was no follow‐up beyond the intervention. Taha 2015 undertook an RCT to explore the intervention outcomes and mechanisms of a culturally informed intervention, the Grady Nia Project, designed for low‐income, African American women with a history of intimate partner abuse and suicide attempt. The intervention was group‐based and therefore not fitting our definition of advocacy. However, the study authors used multivariate general linear modelling with mediation analyses of potential mechanisms and outcomes that was relevant to this review, using data from 89 women who completed both pre‐ and post‐intervention assessments. We included three papers from this project as a result.
  14. We also included two studies that did not consider IPV but that provided useful information on advocacy and its mechanisms. One of these, by Goodman 2009, considered a US programme called ROAD (Reaching Out About Depression). This was designed for women on low income with depression rather than IPV but the exploration of its advocacy element was useful in developing our theory. ROAD paired a mental health counselling student volunteer (master's level) with an interest in social issues with a woman eligible for support. Advocate–woman teams worked together in flexible ways at individual, interpersonal, familial and systemic levels, and advocates provided emotional and instrumental support. The main aims were to alleviate the women's acute crises (e.g. threatened evictions, loss of benefits), and to facilitate their short‐ and long‐term goals, with the women's needs kept central. Advocates often accompanied the woman to community agencies. Pairs met weekly for four to six hours each week for nine months, after which, women had the option of continuing with a new advocate. Goodman 2009 interviewed seven women who had received support from an advocate (two for one year and five for two years) and had subsequently become workshop facilitators within the larger ROAD intervention, six months to three years before interview. In the other study in this category, Scheer 2018 explored mechanisms mediating the relationship between trauma‐informed care (TIC) and health in 227 LGBTQ adults, using structural equation modelling (SEM). They recruited participants from national and local online fora and listservs and hence these findings are not relevant to advocacy interventions. Trauma was related to sexuality, and participants were not all women, though all were abused. Nonetheless we have included this study because it provides information on mechanisms of TIC that accords with studies of woman‐focused advocacy.
  15. We included one systematic review: Shorey 2014.
  16. Although we excluded El‐Mohandes 2011 from this review, the relevant data were published in a subsequent paper that is included in the review (Kiely 2010); see Characteristics of included studies for further details. We did not consider sister papers of other studies if they were not relevant to our main questions but if we were able to exclude them from their abstracts they do not appear in our Characteristics of excluded studies list. Thus this review, unlike Rivas 2015, was not exhaustive in its inclusion if articles, in keeping with our realist approach.
  17. Garcia‐Leeds 2017 undertook a qualitative study about an intervention that provided families with several services, support in aspects related to other agencies (working with these agencies on the women's behalf), information about laws and services available to undocumented users, a crisis line and community educational workshops related to domestic violence.
  18. Initially we identified 11 essential principles from the literature, which were checked and enriched by the stakeholder group input. This group made the principles more precise, for example in defining terms such as 'vulnerable and marginalised women'. In this review we take the view that marginalisation is both a process and a state. It refers to the relegation to the fringes of society of an individual or group because they cannot access societal rights, resources, and opportunities and so cannot fully participate in social, economic and political life. As such, marginalisation is multi‐layered and complex, being rooted in interconnected economic, social, environmental, and political systems. It leads to greater vulnerability, vulnerable people being broadly considered as individuals or groups with a status that may adversely impact upon their well‐being, which they are unable to adequately protect (Walker 2018; Wrigley 2016). All abused women may be considered as marginalised and vulnerable to at least some degree, but in this review we use these interconnected terms to refer to women who are particularly limited in their access to rights, resources and opportunities through their economic, physical, legal, or geographic states.
  19. Six studies included social support components (Constantino 2005;Coker 2012;Goodman 2016a;Murray 2015;Lako 2018;Sudderth 2017). Constantino 2005 found that a social support intervention for women in shelters decreased their psychological distress and increased the perceived availability of social support. The study by Coker 2012 showed that when the social support scores of women experiencing IPV increased, anxiety and depression levels, post‐traumatic stress disorder symptoms and suicide attempts decreased. Advocates in the Goodman 2016a study encouraged shelter residents to socialise with each other both inside and outside the shelter. They considered that by sharing views and experiences, and by attending social events together, women would become more empowered and confident and better able to reintegrate into society. Goodman 2016a and Murray 2015 also explored how some advocates worked directly with members of the woman's immediate network to ensure they were sources of support and not harm. This necessitated educating network members about IPV and about available services for survivors (including running educational workshops within the local community) but also the provision of emotional support for network members who were themselves emotionally affected by the woman's abuse (Goodman 2016a). As one advocate said:
  20. Song 2012 conducted a survey of 191 abused women who had received services from the centres of Prevention and Intervention for Domestic Violence or from the private IPV sector in Taiwan. Services were not necessarily advocacy, but findings support other studies included in this review. When modelling direct and indirect effects on outcomes, a path analysis showed that one of the three most influential variables on empowerment was negative impact of the abuse (a composite variable that included fear, severity and type of abuse) (beta = 0.27), which had a direct positive effect on change of self (including self‐affirmation and enhanced ability to use resources), where the resources were varied and not just related to criminal justice.
  21. This review was partly funded by the NIHR Cochrane Incentive Scheme 2017 (project reference 17/62/37). The views and opinions are those of the author and do not necessarily reflect those of the NIHR, NHS, or the Department of Health (England).
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Related

Authors
Rivas, C., Vigurs, C., Cameron, J., & Yeo, L.
Affiliations
  • University College London (GB)
  • The University of Melbourne (AU)
  • KK Women's and Children's Hospital (SG)
ORCID
Venue
Cochrane Database of Systematic Reviews
Publisher
Wiley
Published
2019-06-29
Volume
2019
Issue
6
Pages
CD013135-CD013135
ISSN
  • 1361-6137 (ISSN-L)
  • 1465-1858
DOI
10.1002/14651858.cd013135.pub2
PMC
PMC6598804
OpenAlex
W2954387386
Cited by
65
References
325
Citations by year
2026: 3 · 2025: 10 · 2024: 13 · 2023: 10 · 2022: 10 · 2021: 10 · 2020: 5 · 2019: 4
FWCI
1.54
Type
journal article
Language
en
Open access
Locations
  • Cochrane Database of Systematic Reviews (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • UCL Discovery (University College London) (submittedVersion)
  • Figshare (submittedVersion)
  • Research Online (University of Wollongong)
Topics
  • Social Sciences › Health › Intimate Partner and Family Violence
  • Social Sciences › Demography › Elder Abuse and Neglect
  • Social Sciences › Gender Studies › Sexual Assault and Victimization Studies
Keywords
advocacy interventions, intimate partner violence, domestic violence, battered women, coercive control, safety planning, theory development, intervention effectiveness, revictimization, lawyers, women's empowerment
MeSH terms
Adolescent, Adult, Female, Health Services Needs and Demand, Humans, Patient Advocacy, Surveys and Questionnaires, Safety, Spouse Abuse, Randomized Controlled Trials as Topic, Crime Victims, Qualitative Research

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