Background: There is a strong association between exposure to intimate partner violence (IPV) and the development of negative mental health (MH) outcomes among women and their children. Given the high prevalence of IPV in low and lower-middle income countries (LLMICs) and its relationship with varying MH issues, it is essential to identify evidence-based interventions that reduce MH challenges, including interventions that remain effective under LLMIC resource, implementation, and scalability constraints.
Objective: The proposed study involves a systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating psychosocial interventions compared to a) no intervention, b) alternatively specified interventions, or c) waitlisted services to reduce MH impairment among women and children with IPV exposure and who live in LLMICs relative to those living in high income countries (HICs).
Methods: Our methods and reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We systematically searched eight electronic databases for RCTs reporting the effects of psychosocial interventions on the well-being of women, and/or their children, who were exposed to IPV and who were living in LLMICs or HICs. Searches were completed on April 10, 2022. We implemented forward citation searching on February 19th, 2023, of the included studies to capture any missed or recently published papers. Title, abstract, full-text screening, and data extraction were completed independently, using Covidence. Primary and secondary outcome data extracted and analyzed from the included studies were: (a) MH disorder (depressive disorder, anxiety disorder, post-traumatic stress disorder (PTSD)), (b) clinical symptoms of mental illness (stress, emotion dysregulation, self-efficacy, self-esteem, externalizing symptoms, and suicidal thoughts and ideation) and (c) parent and child relationship and quality of life. Pooled effect estimates of the outcomes were synthesized on Comprehensive Meta-Analysis (CMA) and were reported using Hedge’s g. Risk of bias was also assessed, in duplicate, using the Clarity Risk of Bias Tool and the certainty of the available evidence was classified according to the Grading of Recommendations Assessment, Development and Evaluation Tool (GRADE). Where at least five studies were available for an outcome, three a priori subgroup analyses were completed for women and children on the basis of : 1) psychosocial intervention type (empowerment and advocacy, trauma-focused therapy, non-trauma focused therapy, counselling, and cognitive behavioural therapy (CBT), and parenting), income setting (LLMIC and HIC), and 3) length of follow-up (post-intervention, < 12-months follow-up, and ≥ 12-months follow-up). Lastly, sensitivity analyses explored the impact of the following on the outcomes (1) high-risk of bias ratings; (2) missing data, and (3) reporting on feasibility and pilot data.
Results: A total of 33,257 articles were identified via database searches; 12,057 were removed using deduplication, resulting in 21, 200 articles for title and abstract screening. A total of 581 articles underwent full-text screening, of which 55 unique studies were included in the review. Across the included studies, enough data was available to analyze seven outcomes within the meta-analysis; this included the primary outcomes of depressive disorder, anxiety disorder, PTSD, and the secondary outcomes, stress, self-esteem, self-efficacy, and quality of life. Thirteen studies were completed in LLMIC settings, with 42 studies focused on HICs. Ten studies focused on women and children exposed to IPV, 43 studies focused strictly on women, and two studies focused strictly on children. With respect to the outcomes, the majority of studies examined intervention impacts on depression (k = 33, 60%), anxiety (k = 11, 20%), and PTSD (k = 26, 47%). After performing the meta-analyses, very uncertain evidence suggests that psychosocial interventions may lead to reductions in maternal depression (g = -0.222; 95% CI -0.353 to -0.090) maternal anxiety (g = -0.541; 95% CI -0.953 to -0.129), and child PTSD (g = -0.314; 95% CI -0.602 to -0.026). Additionally, very uncertain evidence suggests that psychosocial interventions may have little to no effect on child depression (g = 0.085; 95% CI -0.519 to 0.690), maternal PTSD (g = -0.193; 95% CI -0.339 to -0.047), maternal stress (g = -0.188; 95% CI -0.454 to 0.078), and maternal self-efficacy (g = 0.187; 95% CI -0.096, 0.469). As well, moderate certainty of evidence indicates that psychosocial interventions are likely to result in little to no difference in self-esteem (g = 0.196; 95% CI -0.009 to 0.401), and a low certainty of evidence indicates that psychosocial interventions may result in little to no difference in maternal quality of life (g = 0.121; 95% CI -0.090, 0.332), relative to controls. However, when considering these outcomes, trauma-focused therapy showed significant improvements in maternal depression in HICs and LLMICs, while maternal anxiety and PTSD showed significant improvements in LLMICs. Non-trauma focused therapy resulted in significant improvements in maternal stress specifically in LLMICs. Parenting psychosocial interventions were also effective in significantly improving child PTSD in LLMICs.
Conclusion: The systematic review and meta-analysis found that psychosocial interventions may not be more beneficial compared to control groups for addressing MH outcomes amongst women and children exposed to IPV within LLMICs and HICs. While trauma-focused therapy, non-trauma focused therapy, and parenting interventions demonstrated significant positive impacts for maternal depression, anxiety, PTSD, stress and child PTSD, the evidence available was deemed to be uncertain. This review underscores the importance of equal resource distribution, fair research practices, investing in longer follow-up studies, comprehensive data analysis, and clear reporting. Future research should prioritize well-designed trials to understand the effects of specific psychosocial interventions. / Thesis / Master of Science (MSc) / Women's exposure to intimate partner violence (IPV) is a serious public health problem that often occurs in the presence of children and is linked to poor mental health; this is especially true among women and children living in low and lower-middle income countries (LLMIC) (Barada et al., 2021; García-Moreno et al., 2013; Silva et al., 2019). Given that intervening early can help reduce the mental health (MH) impacts of IPV exposure, there is an urgency to identify and disseminate evidence-based interventions in LLMIC settings. Here, we systematically review the literature evaluating psychosocial interventions that aim to reduce MH impairment among women and children exposed to IPV in LLMIC settings and examine how these findings compare to psychosocial interventions that reduce MH impairment among those living in high-income country (HIC) settings. In total, 55 unique studies were included in the systematic review. Findings are varied; however, overall, trauma-focused therapy, non-trauma focused therapy, and parenting psychosocial interventions significantly improved specific mental health outcomes within specific settings. In HICs, trauma-focused therapy demonstrated improvements in maternal depression. In LLMICs, trauma-focused therapy was effective in reducing maternal depression, anxiety, and post-traumatic stress disorder (PTSD). In addition, in LLMICs, only, non-trauma focused therapy improved maternal stress and parenting interventions improved child PTSD. We also narratively and statistically discuss factors specific to the psychosocial interventions that may improve MH following IPV exposure. Intervention factors include mechanism, type, delivery, setting, and modality, which should be targets for future evaluation. In sum, our review emphasizes the importance of tailoring interventions to address the unique needs of survivors in particular settings and calls for balanced, larger, and well-designed trials to better understand the effects of psychosocial interventions within and across contexts.
| Identifer | oai:union.ndltd.org:mcmaster.ca/oai:macsphere.mcmaster.ca:11375/29137 |
| Date | 23 November 2023 |
| Creators | Krishnapillai, Andrea |
| Contributors | Kimber, Melissa, Health Research Methodology |
| Source Sets | McMaster University |
| Language | English |
| Detected Language | English |
| Type | Thesis |
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