Examining the effectiveness of psychological interventions for marginalised and disadvantaged women and individuals who have experienced gender-based violence: protocol for a scoping review.

INTRODUCTION: Exposure to gender-based violence (GBV) has devastating psychological outcomes for victims/survivors. Particularly in conditions where GBV intersects with multiple forms of oppression, the negative impacts of violence are more challenging to overcome and potential pathways for recovery become less accessible. However, evidence regarding the availability and effectiveness of mental health interventions for GBV survivors from marginalised and disadvantaged communities has yet to be systematically integrated and synthesised. The proposed scoping review will examine the relevant literature regarding the availability and effectiveness of psychological interventions for survivors of GBV from marginalised and disadvantaged backgrounds. This review will (i) document what psychological interventions have been available and empirically established for marginalised and disadvantaged women and individuals with experiences of GBV, (ii) provide a narrative examination of the treatment outcomes of identified interventions regarding their effectiveness and (iii) examine the degree to which GBV interventions in selected sources are designed and applied with a recognition of the social determinants of mental health. METHODS AND ANALYSIS: The search for the proposed scoping review will include five electronic databases: PsycINFO, Scopus, Web of Science, Ovid Medline, and CINAHL. The database search will be completed in June 2022. An additional search will be conducted before the completion of the study in December 2022. The search will target research studies published after 2010. The primary eligibility criterion for study selection is having a focus on psychological interventions for GBV survivors from marginalised and disadvantaged groups. Two reviewers will conduct screening and data extraction. The data will be evaluated to map the treatment outcomes of interventions and their effectiveness. Implications for clinical services will be discussed. ETHICS AND DISSEMINATION: No ethical consideration is foreseen for this scoping review. The dissemination will be done through a publication in a top-tier open access journal and conference presentations. © Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

The proposed scoping review will provide a comprehensive overview of the state of evidence on the topic and reveal potential gaps in the literature.

Our search strategies utilise a flexible but rigorous, transparent, and replicable methodological approach to document available information on the topic by including multiple study designs and methodologies.

The proposed scoping review will be the first to systematically integrate and synthesise emerging research evidence on the availability and effectiveness of psychotherapies for gender-based violence survivors from marginalised and disadvantaged communities, which will uniquely contribute to the improvement of inclusiveness and diversity in clinical services.

This review will map the available evidence by providing a narrative, descriptive summary of the findings rather than a quantitative examination and synthesis of research evidence.

The search will be limited to the sources written in English and published after 2010 and will not include any theoretical/conceptual articles written on the topic.

Introduction

Background and rationale

Gender-based violence (GBV) is a global problem and human rights violation affecting at least one in three women worldwide, having long-term adverse effects on survivors’ physical, social, psychological and economic well-being.1 Psychological studies have documented the negative mental health consequences of GBV.2 The prevalence of psychological distress and comorbid mental health difficulties (ie, post-traumatic stress disorder (PTSD), depression, anxiety, substance abuse, suicidal ideation) is reported to be substantially higher for women and individuals affected by GBV.1 3–6 These findings have also led to the design and evaluation of clinical interventions for survivors.7 Besides supportive counselling, advocacy, and empowerment work as part of violence intervention and prevention programmes, studies have illustrated the effectiveness of various evidence-based treatment modalities (ie, cognitive-behavioural therapies, trauma-focused treatments, solution-focused interventions, eye movement desensitisation and reprocessing therapy) in reducing the negative consequences of violence on the psychosocial well-being of survivors.8–10

Despite promising findings reported in the existing psychotherapy literature on GBV, the extent to which these intervention models are empirically established for marginalised and disadvantaged women and individuals (ie, Black women or women of colour, refugee or immigrant women, women with disabilities, poor women, transgender or gender nonconforming individuals) remains unanswered.11 12 Although evidence-based interventions appear effective in relieving traumatic stress symptoms and improving clients’ well-being,9 the effectiveness of these interventions with clients from diverse social locations remains unclear.11 12 Reflecting the inequities and social disparities in clinical mental health research,13 14 this lack of information creates a risk of overlooking unique needs of people with low social power in psychotherapy practice; and thus, makes mental health services less accessible and available for them.11

In this proposed scoping review, we will synthesise the existing knowledge in the literature regarding the availability and effectiveness of psychotherapy interventions for marginalised and disadvantaged women and individuals with experiences of GBV. To the best of our knowledge, there are two broader systematic review studies that examined the effectiveness of mental health interventions for women who have experienced intimate partner violence. However, these studies do not focus on the context of marginalisation and disadvantage.9 15 Also, several studies have reviewed psychological interventions for GBV in the context of specific settings of marginalisation. One study, for instance, focused on psychological treatments in low-income and middle-income settings in terms of their effectiveness in preventing intimate partner violence.10 Another study examined the effectiveness of mental health intervention strategies in improving the psychological well-being of survivors/victims in areas of armed conflict.16 Additionally, a scoping review study conducted in 2019 investigated the treatment effectiveness of psychological interventions for people with diverse sexual orientation and/or gender identities in the context of intimate partner violence.17

In our scoping review, rather than focusing on a particular setting of marginalisation and disadvantage, we will extend on the previous studies by examining any forms of intersecting marginalisation related to ethnic/racial identity, cultural identity, gender identity, sexual orientation, geography, immigration status, (dis)ability and/or socioeconomic class. Based on this objective, we will systematically review the related studies in the literature to answer two primary questions: (i) what psychological interventions are available and have been empirically established for minoritised women and individuals who have experiences of GBV and (ii) what are the outcomes of these existing psychological interventions? By investigating these broader questions, the present review will offer crucial outputs for informing intersectionality-focused and survivor-focused mental health services for marginalised, disadvantaged women and individuals affected by GBV.

Intersectionality in trauma care for GBV survivors

Intersectionality theory18 is a systemic perspective for analysing and understanding how the systems of power and privilege constitute people’s experiences of oppression and marginalisation.13 14 19 It addresses the complicated ways of how individuals belong to multiple social positions simultaneously (based on their characteristics such as gender, race, ethnicity, cultural background, socioeconomic class, age, dis/ability status, sexual orientation, religious beliefs and/or immigration/citizenship status) and how this simultaneity shapes people’s continuously changing positions in social power relations.13 14 Today, an increasing number of scholars working with mental health and trauma underscore the key importance of intersectionality-informed psychology research and practice.12 14 20 21 An important aspect of this emphasis is to ensure proper attention to disempowered individuals and groups as their experiences have been historically overlooked in psychology research. This focus, first, encompasses an exhaustive understanding of how historical and continuous social processes create diversity in human experiences and social locations of privilege and disadvantage.13 Furthermore, in terms of the conceptualisation of individual trauma and trauma recovery interventions, intersectionality informed approaches necessitate exploration of how and in which ways societal and historical inequalities and injustices affect people’s psychosocial well-being and shape their personal and collective experiences of distress and trauma.12 20

Considering the interpersonal trauma in the context of GBV, clinical literature still lacks an intersectionality perspective and overlooks social determinants of mental health.14 22 Social determinants of health address broader social and economic circumstances that determine the health of individuals and communities.23 These circumstances mainly shape the availability and accessibility of resources and services for individuals and communities. They include income status, employment conditions, social and living conditions, racial/ethnic minority status, immigration status, cultural identity, sexual orientation, gender identity and/or disability.23 Thus, overlooking these intersecting circumstances, in conjunction with a medical, psychiatric model of trauma and mental health, results in many psychotherapeutic modalities failing to provide context-informed services for survivors of violence.12 That is, the mental health outcomes of violence (particularly PTSD) are often taken as directly created by the experiences of violence itself, without consideration of how different individuals, depending on their social locations, react differently to violence and what diverse needs they have for trauma recovery.12 19 24 This is particularly marked for marginalised and disadvantaged populations, as the specific trauma of interpersonal violence becomes part of people’s broader suffering based on collective experiences of injustice and inequality.25

Survivors of violence from marginalised or disadvantaged communities are more likely to experience long-term traumatic consequences of violence, as victimisation intersects with systemic racism, racialised trauma, intergenerational trauma, immigration distress and class-based or disability-based discrimination.12 Most treatments exclusively focus on the individual cognitive and emotional responses triggered by singular traumatic experiences such as GBV. This may limit the effectiveness of treatments for marginalised women and individuals, which, in turn, become an additional barrier for them to benefit mental health services.11

Objectives of the proposed scoping review

The proposed scoping review aims to examine the availability and effectiveness of current mental health services for GBV survivors from marginalised and disadvantaged communities. We propose this question first to investigate the degree of diversity and heterogeneity in the sampling of available studies, mainly regarding the inclusion of marginalised and disadvantaged individuals in related psychotherapy research. We are interested in any forms of intersecting marginalisation related to ethnicity/race, cultural identity, gender identity, sexual orientation, geography (ie, rural/urban, low-income countries and conflict/war zones), immigration status, (dis)ability and/or socioeconomic class. Second, we will document what treatment outcomes were measured in the identified studies and review the findings regarding the effectiveness of the interventions in achieving these outcomes. Furthermore, we aim to examine to what degree existing psychotherapy modalities, as presented in the available research, incorporate the social determinants of mental health (ie, income inequality, unemployment, low educational attainment, housing instability, experiences of marginalisation and discrimination, unequal access to services and resources, and community/culture level barriers) into their approach as a part of healing from the trauma of GBV. That is, we want to explore the degree to which GBV interventions in psychotherapy settings are designed and applied with recognition of clients’ social locations and their lived experiences of multiple forms of inequalities and injustices in shaping their trauma and recovery processes.

Methods

Eligibility criteria for study selection

The present scoping review protocol has been developed adhering to the ‘Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews’.26 Besides the use of the PRISMA guideline, this review also utilises the PCC framework (Population/Concept/Context) as recommended by the Joanna Briggs Institute (JBI)27 to inform its search strategy. Accordingly, a search string has been designed based on three research areas: ‘Marginalised and disadvantaged women/individuals’ (population/sample), ‘GBV’ (concept/topic), and ‘psychotherapy’ (context/intervention setting). Each area consists of a comprehensive list of keywords/search terms. See online supplemental material 1 for a complete list of search keywords. The search strategies have been developed in collaboration with the research information specialists (liaison librarians). This protocol was submitted for registration to Open Science Framework Registries on 7 June 2022 (Registration DOI: 10.17605/OSF.IO/HAQS6).

A search for eligible studies will be conducted within five different databases: PsycINFO, Web of Science, Scopus, Ovid Medline, and CINAHL. See online supplemental material 2 for complete search strategy for Scopus. Search strategies will be further adapted and refined accordingly to specific database requirements. An additional strategy to identify relevant publications will include hand-searching of the reference lists of eligible studies. The searches will be restricted to publications written in English. Although we considered conducting the search without date limitation, the number of results based on our preliminary search was not feasible to screen. Thus, besides ensuring that there was a manageable number of resources to screen, as we are also interested in most contemporary practices, we decided to limit our search to research articles published after 2010.

Our search strategies utilise a rigorous and transparent approach28 to document available information on the topic by including multiple study designs and methodologies. Sources that utilise any of the following methodologies will be eligible to be included in the review: randomised controlled design, quasiexperimental design (non-randomised controlled design), qualitative methodology (individual interviews, focus groups and participatory methodologies), cross-sectional or longitudinal study designs, case–control studies or mixed-method study designs. Reviews, conference proceedings, abstracts, book chapters, letters, comments, animal studies or single-case studies will not be considered for analysis. A citation software, Zotero, will be utilised to store and merge all bibliographic information. The scoping review will be conducted from June 2022 until December 2022. Before the completion of the study, an additional database search will be conducted based on the previously established strategies to include newly published sources in the review (if there are any) after the first conduct of the search.

Study screening process

A screening form has been developed to be used by the reviewers during the study selection process. The form is presented in online supplemental material 3. First, the titles and abstracts of all potentially relevant academic literature publications will be screened by two reviewers. Then, the screened studies will be categorised by the reviewers as ‘relevant’, ‘irrelevant’ or ‘unsure’. In case of any discrepant assessment between the reviewers, a third reviewer will conduct an independent screening to resolve the disagreement. As the second step of the screening process, for the sources marked as ‘relevant’ and ‘unsure’, a full-text screening will be independently conducted by the two original reviewers. The publications that remain marked as ‘unsure’ at this step will be screened and discussed by the whole team, and a final decision will be taken based on a collective agreement. A review management software, Covidence, will be used for the screening process.

Data extraction

A data extraction form has been created to be used by two reviewers during the process of full-text analysis of the selected sources. This form will be pilot tested on 20 articles considered as ‘relevant’ for the review, and, if necessary, relevant adjustments will be made to establish the inter-rater reliability and strengthen the functionality of the form. See online supplemental material 4 for the data extraction form. As with the screening process, Covidence will be utilised for the data extraction. The methodological quality of the selected studies will be assessed according to the JBI’s critical appraisal tools.29 As the JBI’s critical appraisal tools include separate checklists for different methodologies (ie, checklists for qualitative studies, randomised controlled trials, or quasi-experimental designs), the studies will be evaluated in terms of trustworthiness and any possibility of study bias according to the applied methodology of the sources. All selected studies will be marked as ‘high-quality’, ‘low-quality’ or ‘uncertain’. The identified quality issues will be evaluated and discussed in the final scoping review article.

Data synthesis

The findings will be synthesised and reported through three strategies. First, a PRISMA flowchart will be created to present the overall scoping review process, which aims to provide a numerical summary of the identification, screening and inclusion/exclusion processes. Second, a table will be used to summarise and present the following data extracted from each included source: citation details, methodology/design, research questions/hypothesis, population/context, main findings/outcomes, strengths and limitations. Third, a narrative synthesis approach30 will be followed to explain the findings of selected sources. That means, our data synthesis will be primarily based on ‘the use of words and text’ (30 p.5) to describe and evaluate key findings/ themes as presented in selected sources. This analysis will aim providing a critical examination of available evidence regarding inclusion of marginalised and disadvantaged women and individuals in psychological intervention research for GBV. For this narrative synthesis, we will focus on three pre-determined questions:

Which setting(s) of marginalisation and disadvantage did selected studies focus on?

Whether and how did selected studies address social determinants of health—related to the setting(s) of marginalisation and disadvantage—in shaping intervention modalities that were measured (ie, testing cultural appropriateness of interventions; adjustment of intervention strategies according to the diverse needs of marginalised/minoritised clients; issues related to accessibility and availability of interventions; addressing intersecting/collective sources of trauma and distress beyond GBV such as intergenerational trauma, racism, or class-based discriminations)?

What type of treatment outcomes did selected studies focus on and to what degree were these outcomes identified as effective?

Patient and public involvement

There is no patient and public involvement in this scoping review.

Ethics and dissemination

After the completion of the scoping review process, the results of the scoping review will be disseminated through a publication in a top-tier peer-reviewed open access journal and conference presentations. In addition, a detailed online community report based on the review findings will be prepared to be shared with various stakeholders working in mental healthcare and GBV fields. An online workshop will also be organised to discuss the implications of the findings with relevant community partner organisations. The present scoping review includes no ethical considerations and, thus, requires no ethics approval.