Women's experiences and expectations of intimate partner abuse identification in healthcare settings: a qualitative evidence synthesis.

OBJECTIVES: To explore women's experiences and expectations of intimate partner abuse (IPA) disclosure and identification in healthcare settings, focusing on the process of disclosure/identification rather than the healthcare responses that come afterwards.
DESIGN: Systematic review and meta-synthesis of qualitative studies DATA SOURCES: Relevant studies were sourced by using keywords to search the databases MEDLINE, EMBASE, CINAHL, PsychINFO, SocINDEX and ASSIA in September 2021. ELIGIBILITY CRITERIA: Studies needed to focus on women's views about IPA disclosure and identification in healthcare settings, use qualitative methods and have been published in the last 5 years. DATA EXTRACTION AND SYNTHESIS: Relevant data were extracted into a customised template. The Critical Appraisal Skills Programme checklist for qualitative research was used to assess the methodological quality of included studies. A thematic synthesis approach was applied to the data, and confidence in the findings was appraised using The Confidence in the Evidence from Reviews of Qualitative research methods.
RESULTS: Thirty-four studies were included from a range of healthcare settings and countries. Three key themes were generated through analysing their data: (1) Provide universal education, (2) Create a safe and supportive environment for disclosure and (3) It is about how you ask. Included papers were rated overall as being of moderate quality, and moderate-high confidence was placed in the review findings.
CONCLUSIONS: Women in the included studies articulated a desire to routinely receive information about IPA, lending support to a universal education approach that equips all women with an understanding of IPA and options for assistance, regardless of disclosure. Women's suggestions for how to promote an environment conducive to disclosure and how to enquire about IPA have clear implications for clinical practice.PROSPERO registration numberCRD42018091523. © 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.

This study used an extensive search strategy and well-defined study selection criteria.

Systematic, transparent methods were used to extract data, appraise the quality of included papers and assess confidence in the findings.

Multiple reviewers were engaged at each stage in the research process, some highly experienced in conducting systematic reviews.

A limitation of this study is the lack of data relating to the experiences of women in marginalised groups.

There are some concerns regarding the utility of quality appraisal techniques for qualitative research.

Introduction

Intimate partner abuse (IPA)—defined as the behaviour of a current or former intimate partner that causes psychological, physical or sexual harm—is a serious public health and human rights issue.1 It is estimated to affect almost one-third of women worldwide and is linked to a range of serious short and long-term health consequences.1 2 These include chronic pain, suicidal ideation, gynaecological issues, depression, addiction and death.2 While any individual can be the victim of IPA, it is largely a gendered experience, with women being the targets of more severe physical violence, sexual violence and coercive control from their male partners.1 To prevent IPA and effectively support those experiencing it, action is required at multiple levels alongside an understanding of the social norms and structural inequalities that maintain violence against women.3–5

Healthcare practitioners (HCPs) are in a critical position to assist those experiencing IPA.1 Women exposed to IPA present disproportionately in healthcare settings, particularly in emergency, obstetrics and gynaecology, mental health and addiction services.6 7 Studies indicate that of all professionals, survivors most trust HCPs to discuss IPA and that they want to be asked about it.1 8 For many women, healthcare settings also have the advantage of an established relationship with a HCP and are safe, confidential environments.6 HCPs can deliver immediate care for the range of health conditions that may be caused or complicated by IPA as well as an empathetic response that can help women understand their experiences.1 9 In addition, HCPs can provide a first-line response, documentation and referral to specialist support services that may assist women in their long-term safety and well-being.1 6

Providing women with support first requires their exposure to IPA to be recognised. Despite the high prevalence of IPA and the dangerous nature of an abusive relationship, many women do not seek help early.10 11 Women’s disclosure of IPA has been described in the literature as a non-linear process that is influenced by anticipated risks and benefits.4 12 13 Barriers to disclosure for women include fear, isolation, shame, self-blame and the belief that healthcare services are not able to offer help.4 10 11 14 Many barriers also exist to practitioner-led identification, despite the fact that almost all HCPs will at some point care for patients who have experienced IPA.15 16 These include a reluctance to interfere in a patient’s ‘private’ issues, frustration and feelings of helplessness when patients do not take their advice, and resistance to taking responsibility for dealing with IPA.15

Several clinical guidelines have recently been developed to assist HCPs in responding to IPA. For example, a comprehensive resource of evidence-based guidelines was released by the WHO in 2013.1 It recommends the provision of women-centred clinical and psychological care, be an integrated part of practitioner training. These guidelines include a discussion around the importance of identifying women experiencing IPA, strongly recommending that HCPs enquire about exposure when assessing health conditions linked to IPA. It also establishes several minimum requirements for asking about IPA, including that HCPs are trained in how to ask and respond, that it is conducted in a private setting, and with referral systems in place.1 The implementation of best practice guidelines such as these are an important part of safely and effectively identifying those experiencing IPA, yet it is unclear to what extent they have been normalised into practice.

In 2006, a meta-synthesis of qualitative research was published exploring women’s experiences and expectations of HCPs in identifying and responding to IPA.10 This paper found that women wanted HCPs to raise the issue in a sensitive way, without pressuring them to disclose. Women expressed that their preferred form of identification was dependent on their relationship to the HCP, and that both verbal and non-verbal indicators of IPA should be attended to. Even if a woman chose not to disclose, having had the HCP raise the issue in a sensitive way demonstrated trustworthiness and could facilitate disclosure at a later date.10 In the 15 years, since this meta-synthesis was published, IPA has increasingly received public and academic attention.1 17 18 We, therefore, sought to undertake an updated systematic review and qualitative evidence synthesis to understand what, if anything, has changed in women’s experiences and expectations of disclosure in healthcare settings. We chose to focus on the process of disclosure/identification of IPA rather than the healthcare responses that come afterwards, which are explored in a separate paper.19 Although a recent review by Heron and Eisma18 also addresses a similar topic, their review focuses primarily on barriers and facilitators to disclosure, whereas we have chosen to highlight the ways that women perceive HCPs and how health settings can more effectively promote disclosure and identification of IPA.

Methods

Our methodology was based on Cochrane guidelines.20 The specific research question for this systematic review was: What are women’s experiences and expectations of IPA disclosure and identification in healthcare settings? Ethics approval was not required for this project; however, any ethical issues within the primary literature were considered during the quality appraisal process. The protocol for this review was registered with PROSPERO.

Search strategy

The key terms ‘women’, ‘qualitative research’, ‘IPA’, and ‘healthcare setting’ were identified. Synonyms for each of these terms were then combined in a range of online databases. The Boolean operators ‘OR’ and ‘AND’ were used to combine all synonyms within a category of key terms and to combine each category. Various commands were employed to enable multiple spellings and positionings of key terms, which were then mapped to relevant subject headings and search fields. See online supplemental file 1 for full search strategy.

In September 2021, this search strategy was used in the bibliographic databases MEDLINE, EMBASE, CINAHL, SocINDEX, PsycINFO and ASSIA. Grey literature was included through a search of GreyLit and OpenGrey databases. A non-systematic search was also conducted through Google Scholar, forward citations, reference checking and expert consultation. These literature sources were selected to allow for the inclusion of multiple perspectives on the issue from a range of healthcare settings.

Inclusion and exclusion criteria

To be included, articles must have been published from 2016 onwards. There was no restriction on geographic location nor language. Studies were excluded if they met one or more of the following conditions: (1) focus was not on women’s experiences or expectations of IPA disclosure or identification, (2) participants were not women experiencing IPA or were indistinguishable from other participants in analyses, (3) was not a primary study in a healthcare setting or (4) qualitative methods were not used for both data collection and analysis. Two independent reviewers used the programme Covidence21 to first screen titles and abstracts, then full text papers, against these criteria. A third reviewer then resolved any disagreements over study inclusion. These criteria were selected to locate papers closely aligned with the research question, and the engagement of multiple members of the research team promoted accuracy throughout the screening process.

Data extraction

Papers that were included after full-text screening underwent a process of data extraction. Relevant data were copied into a specifically designed form, then checked for accuracy by a second reviewer. The data extraction template included the setting, objectives, sample characteristics, methods of data collection and analysis, qualitative design, supporting quotations and conclusions of reviewed articles. These documents were then imported into the qualitative data analysis programme NVivo V.12,22 to assist in the organisation and development of themes.

Quality appraisal

The methodological quality of each included article was assessed using a modified version of the Critical Appraisal Skills Program (CASP) checklist for qualitative research.23 This framework was employed as a transparent method of critical appraisal and included 10 questions regarding the validity and value of results.23 Scores were used to easily visualise their assessed quality, with two points assigned to a criterion that was completely met, one point awarded when an item was partially fulfilled, and zero given when left unaddressed. For the final CASP criterion, ‘How valuable is the research?’, a judgement was made based on the originality and significance of the study, with two points given when a paper was appraised to be valuable and one point as somewhat valuable. A total score of 20 was deemed to reflect a high-quality study, 16–19 moderate quality and 15 or below as low quality, a scoring system based on a systematic review by Njau et al.24 One reviewer (EK-C) applied the CASP checklist to each included study, and a second reviewer (MK-O) checked for discrepancies.

Data analysis

Data analysis occurred using the thematic synthesis approach proposed by Thomas and Hardin.25 This involved immersion in the data and line-by-line coding of both participant quotes and author interpretations. Initial codes with a shared meaning were then grouped together to form descriptive themes. The views captured in these descriptive themes were interpreted and combined to create analytical themes representing women’s experiences and expectations of IPA disclosure and identification.25 Members of the research team met several times throughout this process to discuss and refine the developing themes. A thematic synthesis approach was selected as it functions as an accessible method of analysis that maintains a clear link between the primary studies and any conclusions formed.25 26 The combined analysis of author interpretations and participant quotes differs from other methods of qualitative meta-synthesis, such as that employed in the original review by Feder et al,10 in which the text was coded for first, second and third-order constructs.

Assessment of confidence in the findings

The Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual)27 framework was used to assess each theme developed from the literature. The CER-Qual framework provides an assessment of how closely the review themes represent the phenomenon of interest. Four key components were involved in this appraisal process: methodological limitations, coherence, adequacy and relevance.27 After the methodological limitations were assessed using the CASP,23 28 coherence was evaluated by reviewing the fit between the primary data and the review findings.29 Adequacy was determined by assessing the depth of data supporting a synthesis theme,30 and relevance was appraised through a comparison of each finding to the context of the research question.31

Review author reflexivity

The authors recognise that their views regarding the context and dynamics of IPA and the role of the healthcare system may have affected their interpretation of the data. The authors are comprised of students and academics working across the areas of social science, healthcare and violence, some with and some without a practitioner background. All authors approached the topic of this review from the standpoint of seeing the healthcare system as a critical piece of the puzzle in identifying and supporting women experiencing IPA.

Patient and public involvement

No patients were involved in this study.

Results

Study selection

We identified 37 papers describing 34 studies conducted in 17 countries. Figure 1 below illustrates the process of study selection.

Figure 1

Study selection flow diagram. HCP, healthcare practitioner.

Sample characteristics

The 34 included studies represented 17 countries: 13 were conducted in the USA,32–45 4 in Australia,46–51 3 in the UK5 52 53 and 1 each in Ecuador,54 India,55 Israel,56 Japan,57 Kyrgyzstan,58 Mexico,59 New Zealand,60 Nigeria,61 Norway,62 Palestine,63 South Africa,64 Spain,65 Sweden66 and Taiwan.67 The 37 papers resulting from these studies were published in 2016 (n=7), 2017 (n=10), 2018 (n=4), 2019 (n=9), 2020 (n=6) and 2021 (n=1), and included a total of 1016 participants. Participants ranged from 16 to 72 years old, were from diverse ethnic backgrounds and had different family structures. One study, documented in two papers, explored the experiences of Indigenous women in Australia,46 48 one on the perspectives of women with disabilities,65 and no studies included in this review focused on the experiences of women who were not heterosexual. Online supplemental table 1 contains a summary of study characteristics.

Quality of included studies

Most of the included studies were found to be of moderate methodological quality, with six studies appraised as high quality and none as low. Most studies did not consider the relationship between researcher and participants, and several concerns were found relating to data analysis. In contrast, for each study, a qualitative methodology was appropriate, the design and data collection methods addressed the aims of the research, and findings were clearly presented. See table 1 below for the individual criterion and total scores assigned to each study using the CASP checklist for qualitative research.23

Table 1

Critical appraisal of included studies

First author (year of publication)	CASP criteria*
	1	2	3	4	5	6	7	8	9	10	Total score
Almqvist (2018)66	2	2	2	2	2	0	2	1	2	1	16
An (2019)32	2	2	2	1	2	0	2	2	2	2	17
Bacchus (2016a; 2016b)37 41	2	2	2	2	2	2	2	2	2	2	20
Bradbury-Jones (2016)53	2	2	2	2	2	2	2	2	2	2	20
Burry (2020)60	2	2	1	2	2	0	2	1	2	2	16
Childress (2017)58	2	2	2	2	2	1	2	2	2	2	19
Correa (2020)42	2	2	2	2	2	0	1	2	2	2	17
Decker (2017)38	2	2	2	2	2	0	1	1	2	2	16
Dichter (2020)43	2	2	2	2	2	1	2	2	2	2	19
Fawole (2019)61	2	2	2	2	2	1	2	2	2	1	18
Garnweidner-Holme (2017)62	2	2	2	2	2	2	2	1	2	2	19
Grillo (2019)33	2	2	2	2	2	1	2	2	2	2	19
Hatcher (2016)64	2	2	2	2	2	2	2	2	2	2	20
Hester (2017)52	2	2	2	2	2	0	2	1	2	1	16
Jack (2017)39	2	2	2	2	2	1	2	1	2	2	18
Kataoka (2018)57	2	2	2	2	2	0	2	2	2	1	17
Liao (2017)67	2	2	2	0	2	0	2	2	2	2	16
Mackenzie (2019)5	2	2	2	2	2	2	2	2	2	2	20
Manor-Binyamini (2021)56	2	2	2	2	2	0	2	2	2	2	18
Miller (2017)40	2	2	2	2	2	0	2	1	2	2	17
O’Doherty (2016)47	2	2	2	2	2	1	2	2	2	2	19
Reeves (2017)34	2	2	2	2	2	0	2	2	2	2	18
Ruiz-Perez (2017)65	2	2	2	2	2	0	2	2	2	2	18
Sabina (2019)54	2	2	2	1	2	0	2	2	2	1	16
Shaheen (2020)63	2	2	2	2	2	1	2	2	2	2	19
Sorrentino (2020)44	2	2	2	2	2	1	2	2	2	2	19
Spangaro (2019; 2016)46 48	2	2	2	2	2	2	2	2	2	2	20
Spangaro (2019; 2016)49 50	2	2	2	2	2	1	2	2	2	2	19
Srinivasan (2019)51	2	2	2	2	2	1	2	2	2	2	19
Vranda (2016)55	1	2	2	2	2	0	2	1	2	2	16
Wadsworth (2018)35	2	2	2	2	2	0	2	2	2	1	17
Wallin Lundell (2017)59	2	2	2	2	2	1	2	2	2	1	18
Williams (2020)45	2	2	2	2	2	2	2	2	2	2	20
Zelazny (2019)36	2	2	2	2	2	1	2	2	2	2	19

*CASP criteria: 1. Was there a clear statement of the aims of the research? 2. Is a qualitative methodology appropriate? 3. Was the research design appropriate to address the aims of the research? 4. Was the recruitment strategy appropriate to the aims of the research? 5. Was the data collected in a way that addressed the research issue? 6. Has the relationship between researcher and participants been adequately considered? 7. Have ethical issues been taken into consideration? 8. Was the data analysis sufficiently rigorous? 9. Is there a clear statement of findings? 10. How valuable is the research?23 (2=criterion fully met, 1=partially fulfilled, 0=not addressed, total score of 20=high quality, 16–19=moderate quality, and 0–15=low quality.24

CASP, Critical Appraisal Skills Program.

Key themes

Applying a thematic synthesis approach to the data generated three key themes describing women’s experiences and expectations of IPA disclosure and identification in healthcare settings: (1) Provide universal education, (2) Create a safe and supportive environment for disclosure and (3) It is about how you ask. These themes are detailed below, supported by quotations from women in the primary studies.

Provide universal education

The concept of ‘universal education’—meaning the routine provision of information to all women entering a health service, irrespective of risk factors or disclosure—was repeatedly mentioned across the included studies. Women had the expectation that HCPs would raise the issue of IPA and provide them with information, a theme supported by 20 of the included studies.5 32 33 35 37–42 44–46 49 51 57 60–62 65 66 Information could be given independently from or paired with a screening tool and was seen to facilitate both woman-led and practitioner-initiated disclosures. Potential areas of knowledge included understanding the dynamics of a healthy relationship,39 65 the warning signs of IPA,5 33 37 41 the relationship between mental and physical health,33 62 the impact of IPA on children33 39 62 66 and options for assistance.32 39 41 42 45 60 62 66 For some women, it was not until the violence had escalated or they had left the abusive relationship that they sought healthcare support to understand their experiences. Informed by this, participants viewed routinely providing information about IPA as a way to protect and empower women in violent relationships. Several participants explained aspects of IPA that they wished HCPs had spoken to them about earlier:

The constant verbal abuse, you know, people think that “Oh they’re just angry” but they don’t realize that that’s a form of abuse, you know? Red flags like that… Information is power, and this [receiving information early] is really powerful because it took me years after being in treatment to realize the effects that my emotional health had on my physical health33 (p12).

If I would have known what could happen to the baby when the mother is stressed and impatient, and that it’s not only things you eat that influences the health of your child… I think I would have talked about it earlier62 (p5).

The participants emphasised that information should be given routinely to avoid stigmatising women and to provide all women with an understanding of IPA irrespective of their personal experiences. In addition, If HCPs were going to ask questions about IPA, women wanted to be provided with information first about why the HCP was asking and what assistance was available if they did make a disclosure.39 42 45 49 62

I think if they had asked the questions differently or given more information on why they wanted to know and what would be done with the information, people might be more inclined to tell49 (p346).

Participants articulated a desire for written information, such as posters and pamphlets, to be displayed within the safety of their health clinic, so that they could understand their experiences.45 62

But if you, for example—I go to my son’s pediatrician, and I see a booklet in the pediatrician’s office which catches my attention, and I can look at it while I’m sitting. There is a nice one here [at the family justice center], which has a circle. And in that circle it identifies what kind of man is an abusive man. When I read that the first day, I said, “I have all of that,” and I didn’t know I was abused. So if you see in the doctor’s office those little things—how many women go to take their children, and could identify, “This happens to me.” And they might have some numbers in the back that say, “Don’t worry, there are people here who can help you. You will not be deported,” there obviously has to be something that links you directly in a doctor’s office that can help you45 (p5564).

In three of the contributing studies, HCPs were trained to provide women with IPA information cards regardless of disclosure, which were perceived as a demonstration of care and empowerment and helped women understand that HCPs are there to help38 40 49:

It was awesome. She would touch on having, no matter what the situation you're in, there’s something or someplace that can help you. I don't have to be alone in it. That was really huge for me, because I was alone most of the time for the worst part40 (p89).

When considering the practice of routine or universal screening, some participants thought that all women should receive questions about IPA and appreciated being asked themselves.5 37 38 41 46 49 57 61 66

Yes, [to universal screening] so that their treatment can be holistic. Women can easily confide in their doctors61 (p5).

It shows me that I can talk to her about it, if I chose—if I wanted to. If she didn’t ask those questions, then I just wouldn’t even approach the topic with her46 (p795).

However, other participants were uncomfortable with this idea due to the private nature of the topic and believed that IPA enquiry should only be initiated with women who showed specific signs of abuse.5 46 57 61 The conflicting opinions around routine screening perhaps lend support to a universal education approach, as it removes emphasis away from who to ask in giving all women the resources to understand IPA and their options for assistance.

Create a safe and supportive environment for disclosure

Thirty-one of the included studies supported the idea that HCPs need to create a safe and supportive environment to facilitate women’s disclosure.5 32 34–52 54–60 62–67 For many participants, deciding to share their experiences of IPA was a difficult process entangled in a range of fears.5 34 35 37 39 41–43 45–50 52 54–59 62–64 66 67 These fears encompassed two main dimensions: safety for themselves and their children from the perpetrator and concerns relating to the patient–provider interaction. The most commonly expressed fear was that of perpetrator retaliation,5 35 39 41–43 45 50 52 55 57 59 62–64 described below by participants from two studies:

I mean, there has been a lot o’ things that I've went in and no’ told my GP because I thought ‘Somebody’s sitting out in the waiting room’5 (p1167).

I just kept my mouth shut. You know, I was always walking on eggshells like I didn’t want to look up at anybody. I didn’t want to talk to nobody because if I said something wrong that might piss him off, I was getting beat42 (p190).

Women were concerned about having their children removed, partners incarcerated and suffering financial consequences as a result of making a disclosure.5 35 39 42 45 46 48–50 56 62–64

I guess a lot of people, they’re so scared that their kids are gonna get taken away if they seek out help or they’re so scared that their partner’s gonna be put in jail, the partner’s gonna come after them or they’re not gonna have nowhere to live35 (p756).

Women also felt afraid of being judged negatively by the HCP for not seeking help earlier, that they would be blamed for their abuse, or labelled as a victim.5 34 37 39 41–43 47 51 55 59 62 63 66 67

Sometimes it’s hard to talk to somebody, especially when you don't want to be judged… Because that’s what I heard when I got raped—“You did something to have this man rape you”34 (p1177).

I wouldn't say I had a good or a bad relationship with my GP, but it’s just that stigma, I think, of reporting and being a victim… Like your card’s marked5 (p1167).

Considering the many fears implicated in women’s disclosure of IPA, it was viewed as essential that HCPs demonstrate care in their interactions with patients.5 32 34 36–51 56 59 60 62–66

I definitely trusted her and she’s a very caring person. That was really important to me because I hadn’t dared tell anybody about this before47 (p39).

If you are friendly, people are able to be honest and speak to you about their problems. … If a person is warm like the way you talk to me right now, they will find a way to talk about their problems64 (p1342).

Central to this sense of being cared for was the attitude of the HCP and whether they seemed to be actively listening to what the woman had to say.5 32 34 36 37 39 41 42 46 47 51 59 64–66

I’m not gonna wanna sit here and tell all my personal information to someone who’s having like an ‘I don’t care’ attitude… Someone that’s (looking) at me in my eyes and telling me, ‘oh I’m here for you, this is what I do, if you need anyone to talk to I’m here.’ I would want to tell my story to them more than the other person36 (p37).

Unfortunately, several women had experiences with HCPs who did not have a caring attitude, and this influenced their decisions not to seek help.42 43 46–48 50 59 62

They have even said it straight to my face that they don't have time, as other patients who are sicker than me need their time. Since I'm not dying, I should just hold on for a while. When they treat you like that, you don't feel like telling them when they do have time, even if it is only ten minutes later59 (p953).

Women in the included studies had several recommendations for how HCPs can promote a sense of safety and support in their interactions with survivors.5 32 34–37 39 46 48 51 54 57 62 64–66 To create an environment conducive to disclosure, participants suggested that HCPs emphasise confidentiality and conduct consultations in private.5 32 34 36 37 39 41–43 45 49 54 55 57 60 62 63 66

It felt really safe talking to [the nurse] about [my abusive experiences]. She let me know everything that I tell her will be confidential. Once I got it out there too it felt good to actually talk about it… She just listened, listened really well39 (p11).

A participant in a study by Reeves and colleagues highlights how counterproductive, isolating and scary it was to have her abuser present in the healthcare encounter:

Him standing there just made me so nervous… He brought me [there], and [he was] gonna have to take me home. If I [said] the wrong thing, then I'm gonna get [hurt] or it’s gonna be worse when I get home34 (p1174).

The findings from Spangaro et al’s study with Aboriginal Australian women highlight the need for culturally safe care, experienced by the participants as feeling understood and comfortable throughout the healthcare interaction.46 48 When seen in an Aboriginal service, women reported a heightened sense of security that helped them feel safe speaking about their experiences.

Knowing that other Koori girls go there, you know what I mean? If I went to a non-Aboriginal place I would have felt more—I don’t know, not as comfortable46 (p796).

Women in a Spanish study by Ruiz-Perez and colleagues65 discussed the importance of providing disability sensitive care. When healthcare services were not adapted to their needs, women were unable to disclose IPA and access support.

I couldn’t call, I couldn’t get access to any services and if I did they would talk to me and I wouldn’t understand, I think that it’s more difficult for deaf people, because the barrier we face is communication65 (p1061).

Participants spoke of how taking a woman’s disability into account allows for effective and safe provision of care, and the absolute necessity of providing deaf patients with interpreters in all healthcare interactions.65

It is about how you ask

This theme included data from 27 studies.5 32–39 41–51 53 57–64 66 Women in these studies spoke of the importance of the context in which HCPs ask questions about IPA. Participants suggested that HCPs initially focus on building a relationship and fostering a sense of trust.32 34–39 41 43 45–49 62 64 66

Don't just straight out jump into it. Just make friends with them or something first. At least get some type of relationship with them, make them comfortable46 (p799).

Through establishing a relationship, women believed that HCPs would better understand what was happening in their lives, which could inform individually tailored enquiry and help patients open up. Other key considerations were having enough time to talk and impressing the feeling that the women’s issues would be heard.32 38 42 45–47 49 59 63 64 66

Some doctors just—I guess you need to see a thousand patients in a day so you don’t really have time. That’s what pretty much held me back because when I go in the doctor’s office, it’s so rushed and you kinda just feel like he doesn’t care. He just wants to get to the next patient. That’s kinda what took me so long to open up and talk about it45 (p5559).

You often feel stressed when talking during a medical appointment because the staff keeps looking at their watches and you know [that] they have many patients waiting. But with her [HCP] I never felt that way… she made me feel [that] I mattered59 (p953).

In addition to having sufficient time, women suggested that HCPs needed to introduce questions about violence with appropriate timing, such as towards the middle of a healthcare consultation.36 57 60 62

People aren’t so willing to right away give information up so maybe you might have to ask again in the middle of the… appointment or at the end maybe just drop some hints or something and get them comfortable with you talking to them36 (p37).

Participants in the included studies had several suggestions for how HCPs should ask women about their exposure to IPA.33–36 39 44 47 49–51 57 58 61 62 64 66 When considering the wording of a direct IPA enquiry, women suggested that HCPs use straightforward language that was friendly and non-judgmental.36 46 57 60

I know (IPA assessment at the clinic) could be hard because you’re supposed to be in a professional setting but if you just kind of wipe away the certain words that you’re supposed to use when it comes to a patient, the disconnecting words and be like ‘I know it’s scary… I do this for everyone but I have to make sure ‘cause anyone could be hurting so I… got to talk,’ but you have to be the friend. You can’t be the doctor (because) I know some many people are afraid of medical professionals36 (p36).

Women in the included studies articulated a desire to receive questions about non-physical abuse,42 45 50 51 55 63 believing that this would help them recognise their experiences as abuse and as relevant to the healthcare encounter.

Maybe talk about the question a bit more thorough[ly], like, any arguments, dug in a little. Because you think just the hitting but it’s more, it’s verbal. It’s everything50 (p51).

Participants wanted HCPs to recognise the influence of IPA on other health issues, such as multiple abortions and anxiety and suggested that they introduce questions within this context.34 39 45 47 51 53 58 61 63

It could be sort of an opportunity to grab someone that could be vulnerable to other things. Like, say particularly if you’re having like, a second [emergency contraceptive pill] within a couple of weeks, and go “Okay, is there a problem with your contraception, or are you in … a risky situation?”51 (p496).

In addition, women believed that HCPs should link IPA enquiry with children’s development and safety,33 45 50 62 64 66 as explained by a pregnant woman in a South African study by Hatcher and colleagues:

What I know you must say is: “What’s happening to your life is important for your safety and the safety of your child.” That’s the only thing64 (p1342).

Some women spoke of the need for HCPs to use both direct and indirect questions and ask multiple times to help the women feel comfortable opening up about their experiences.35 39 42 44 48–51 60 62–64

It’s just so easy to say yes to “Yeah I’m safe” … I think maybe they should ask more specific questions because it’s bound to hit a nerve, and they’re going to pick up on that… maybe they should ask you if you’re happy [that you're pregnant]35 (p756).

Researcher: in a case where a woman refused to talk about, what should the doctor do? SW03: Ask the first time, and second time, third time63 (p5).

Although women in the included studies largely wanted to be asked about IPA (and asked more than once), they emphasised that the HCP should not try to force disclosures.5 35 37 43 44 48 49

She’s a great doctor. …I feel like I’m going in and I’m talking to people who honestly care who have been my friends for a lifetime and I’m able to be open and honest. So I think it’s the person, I think it’s the way the questions are set up, and I think it’s the presentation. Because everybody is in their own bubble and if you make things where people feel like they’re more interrogated, then we’re less likely to say anything43 (p2659).

When these expectations were met, participants in the included studies were more likely to form a positive relationship with their HCPs and honestly disclose their exposure to IPA.

Confidence in the findings

By applying GRADE-CERQual methods27 to these review findings, the theme ‘Provide universal education’ was appraised as moderate confidence and the themes ‘Create a safe and supportive environment for disclosure’ and ‘It is about how you ask’ were appraised as high confidence. The confidence ratings indicate that these themes are likely to be reasonable representation of women’s experiences and expectations of IPA disclosure and identification in a healthcare setting. See online supplemental table 2 for a detailed GRADE-CERQual evidence profile explaining individual assessments made.

Discussion

Principal findings

This qualitative evidence synthesis was conducted to answer the question: What are women’s experiences and expectations of IPA disclosure and identification in healthcare settings? We sought to capture the more recent research on the topic of how IPA can be addressed in health settings. Overall, the 34 studies included in our review were found to have a moderate level of methodological quality, mostly due to a lack of consideration of the researcher–participant relationship.

Three key themes were developed by analysing the data with a thematic synthesis approach: (1) Provide universal education (suggesting that information provision to all patients may be more useful than universal screening in healthcare settings in terms of facilitating disclosures), (2) Create a safe and supportive environment for disclosure (which emphasised the need for the HCP to demonstrate care and confidentiality in their approach) and (3) It is about how you ask (highlighting the importance of fostering trust and rapport when enquiring about IPA). Using the GRADE-CERQual assessment,27 two themes were graded as high confidence and one as moderate confidence, indicating that they are likely to be reasonable representations of women’s views on the topic.

Significance and implications for practice

Consistent with previous existing research,10 18 19 our review findings highlight the importance of HCP interpersonal skills in facilitating woman-led disclosure. Participants across the included studies articulated that HCPs need to demonstrate a caring, empathetic attitude and skills in active listening to help them feel safe. To further establish a sense of security and support, participants suggested that HCPs emphasise confidentiality and minimise power differentials through shared decision-making. HCP attitudes and a sense of patient–provider connectedness have been established in the literature as enablers of IPA disclosure,45 50 68 and important factors in patient satisfaction and health outcomes more generally.36 69–72 When HCPs failed to meet women’s expectation of a safe environment, they experienced a sense of distrust and disengagement from the healthcare system and were unlikely to feel comfortable disclosing IPA. Additionally, although there were few studies focused on the experiences of women from marginalised groups, the findings suggest that HCPs must adopt practices of cultural safety and disability sensitive care to ensure that healthcare settings are safe and supportive environments for all women.1 46 48 65 73–80

Women’s experiences and expectations documented in this review also demonstrate the value placed on the way that HCPs ask about IPA. Participants expected HCPs to consider the context in which they initiate an enquiry and phrase questions in a way that is sensitive to the difficulties of disclosure. By developing rapport first, having enough time to talk, using straightforward language and asking questions about violence on different occasions, HCPs can establish a setting conducive to disclosure and signal that they are trustworthy. These expectations align with the recommendations from international guidelines that HCPs should ask about IPA in an appropriate way and be prepared to do so more than once.1 The findings are also congruent with the established importance of good communication skills to patient comfort when discussing IPA.10 81

In terms of specific recommendations for practice, the suggestion that HCPs link questions about IPA with women’s health and the health of their children offers a clear route to enquiry which may be particularly helpful for practitioners worried about offending their patients. Studies exploring the perceptions of HCPs consistently indicate that this fear is a very real barrier to enquiry and response.15 Given that a range of clinical conditions may be caused or complicated by IPA, including chronic pain, suicidal ideation, gynaecological issues, depression and addiction, asking about patient exposure is highly relevant to the medical encounter and the provision of appropriate healthcare support.1 6 10 Children also experience detrimental effects from IPA exposure, and studies indicate that children are a significant factor in women’s decisions to seek professional support.6 45 82–86 The findings from this review show that women want to be asked about IPA in the context of wider health issues and the well-being of their children, and that by doing so, HCPs can demonstrate that they are there to offer help.

A novel finding not described in the previous literature10 18 is the emphasis placed on women’s desire to routinely receive information about IPA. While previous debates have focused on universal screening (with limited evidence being found for its effectiveness87) a universal education approach seeks to equip all women with an understanding of IPA and support options, not only those who disclose their experiences.88 Research from the USA indicates that both HCPs and those experiencing IPA find this to be a beneficial and empowering approach.40 88–91 The findings from this review suggest key areas of desired knowledge for women: what constitutes a healthy relationship, warning signs of abuse, the impact of emotional trauma on physical health, how IPA affects children, and options for support. Conversations about IPA were viewed as important to raise in a healthcare setting as they provided a critical opportunity to talk. While the term ‘universal education’ was not articulated by participants in this review, women had experienced the impact of not receiving information when they needed it and spoke of the necessity of all women having access to IPA knowledge and resources. As explored elsewhere,1 40 this could be achieved through the utilisation of IPA education cards to discuss and give to patients (if safe to do so), and the placement of informative posters in healthcare clinics. Future opportunities for universal education (for contexts where the internet is available) might involve referral to online resources, which have shown promise in raising awareness,92 but have yet to be evaluated in healthcare settings. This would have particular relevance for the context of COVID-19, which was not addressed by the studies in this review.

The emphasis placed on universal education by participants in the included studies represents a fundamental shift in women’s experiences and expectations since the previous review by Feder and colleagues10 was conducted. Although Feder’s review does report that the use of posters and brochures in the healthcare setting can raise women’s awareness about the issue of IPA, subsequent studies in the intervening years have been more specific about the role of universal education. In our review, we found that women wanted more detailed information that could potentially help them identify abuse in their relationships and make decisions about what to do next. Provision of this information was not tied to disclosure or inquiry by the HCP but could act as a facilitator to disclosure in the future. We suggest that the provision of universal education might be more woman-centred than universal screening, since it seeks to empower women through awareness and information. Further, it provides opportunities for HCPs to sensitively inquire by using the education materials as a way to broach the subject of IPA with patients.37 41

Strengths and limitations

The use of an extensive search strategy and well-defined study selection criteria act as strengths of this study. Transparency and validity were promoted by using systematic methods to extract data, appraise the quality of included studies and assess confidence in the findings. The engagement of multiple reviewers at each stage in the research process, some highly experienced in conducting systematic reviews, further added to a robust interpretation of the data. An additional key strength of this review is the use of thematic synthesis as the method of analysis. Thematic synthesis, with its focus on the generation of new themes across the dataset,25 allowed our findings to move beyond a simple categorisation of barriers and facilitators towards themes that are more meaningful and relevant to improving healthcare responses to IPA.

The findings from this review also contain some limitations. While the included studies were from a diverse range of countries, research from high-income settings such as the USA and Australia was still over-represented. Furthermore, only one included study explored the perspectives of women with disabilities and one of an Indigenous population, despite these populations of women being at high risk of experiencing IPA.1 46 48 65 77–79 Our study is also limited by methodological concerns regarding the included papers, and the contentious value of relying on quality appraisal checklists in qualitative research.93 Finally, the minor concerns identified using GRADE-CERQual methods27 may limit the level of confidence placed in review findings.

Recommendations for future research

There are several gaps in knowledge that should be addressed by emerging research. More research is required to understand how universal education could most effectively be implemented and the acceptability of this approach in different settings. In addition, future studies should investigate the views of women from low-income countries, as these voices were largely absent from this review. With limited data exploring the perspectives of disabled and Indigenous women, and none relating to those who identified as sexual minorities, there is a clear need for future research to explore the experiences and expectations of IPA disclosure in these marginalised groups.

Conclusion

This systematic review and qualitative evidence synthesis aimed to understand women’s experiences and expectations of IPA disclosure and identification in healthcare settings, focusing on the process of disclosure/identification rather than the healthcare responses that come afterwards. The findings indicate that women want to routinely receive information about IPA, lending support to a universal education approach that equips all women with knowledge and resources. Contemplating disclosure raised significant fears for women, making it essential that HCPs create a safe and supportive environment. Participants also expected HCPs to consider how they ask about IPA and recommended that it be done in a private setting with sufficient time and be linked with the well-being of women and their children. The included studies were from 17 countries spanning six continents, indicating that regardless of geographic boundaries, women want to be informed about IPA and to feel that HCPs consider their safety and comfort. Implementation of the suggestions described in this study may help empower women experiencing IPA to seek healthcare support and improve the confidence of HCPs in their interactions with female patients. Future research should explore the implementation of universal education in different settings and the perspectives of under researched populations.