Abstract
Intimate partner violence (IPV) disproportionately affects marginalized women in the United States. This calls for effective safety planning strategies to reduce the risk for future revictimization and address safety needs of survivors from marginalized groups. This review identified types of interventions that incorporated safety planning and were successful in reducing the risk for future revictimization among IPV survivors from diverse groups, examined elements of safety planning in effective interventions, and described challenges or limitations in safety planning intervention research with marginalized women. A systematic search of five databases was performed. The search resulted in inclusion of 17 studies for synthesis. The included studies were quantitative, U.S.-based, evaluated interventions with a safety planning component, and had an outcome of change in IPV. Effective interventions that incorporated safety planning were empowerment and advocacy focused. Elements included were comprehensive assessments of survivors’ unique needs and situations, educating them about IPV, helping them identify threats to safety, developing a concrete safety plan, facilitating linkage with resources, providing advocacy services as needed, and conducting periodic safety check-ins. For survivors with mental and behavioral health issues, effective interventions included psychotherapeutic approaches along with safety planning to address survivors’ co-occurring health care needs. Although most studies reported positive findings, there were limitations related to designs, methods, adequate inclusion, and representation of marginalized women and cultural considerations. This calls for additional research using rigorous and culturally informed approaches to establish an evidence base for effective interventions that specifically address the safety planning needs of marginalized survivors of IPV.
Keywords: marginalized women, safety planning, intimate partner violence
Intimate partner violence (IPV) disproportionately impacts marginalized women in the United States and may be a contributing factor in reported health disparities among women from marginalized groups. Women experiencing IPV are significantly more likely to experience poor health than those not experiencing IPV, and this is especially true for ethnic minority women (Bent-Goodley, 2007; Stockman et al., 2015). The poor health outcomes of IPV include both mental and physical health concerns such as post-traumatic stress disorder (PTSD), depression, chronic, pain, and HIV (Sabri & Granger, 2018; Stockman et al., 2015). Moreover, IPV can result in fatal outcomes for women in the form of a homicide. Research shows marginalized women are disproportionately affected by homicides (Petrosky et al., 2017). For instance, in an analysis of IPV-related homicides of adult women from 2003 to 2014, using the National Violent Death Reporting System (NVDRS), non-Hispanic Black women had the highest rate of dying by homicide followed by American Indian/Alaskan Native and Hispanic women (Petrosky et al., 2017). Further, foreign-born women have been found to be at high risk for being killed by an intimate partner (Frye et al., 2005; Sabri, Campbell, et al., 2018).
An interplay of factors such as marginalized racial/ethnic identity, socioeconomic status, and immigration status may shape marginalized women’s access to resources, help-seeking behaviors, and their overall safety, health, and well-being. Further, marginalized survivors in abusive relationships may not seek help due to shame and embarrassment, lack of culturally competent services, language barriers, past experiences with discriminatory services, poverty, and immigration status (Bent-Goodley, 2007; Njie-Carr et al., 2020). These barriers may place marginalized survivors of IPV at risk for repeat IPV, severe IPV, and homicide. Indeed, in the analysis of homicides of adult women using the NVDRS, 1 in 10 victims of IPV-related homicide were reported to have experienced IPV in the month preceding their deaths (Petrosky et al., 2017). Other examinations of IPV victimization prior to intimate partner homicide indicate that two thirds to three quarters of female IPH victims were abused by their partners before being killed (Harden et al., 2019). There is a need for timely and effective safety planning interventions that identify at-risk women in abusive relationships and connect them with services to enhance safety.
Safety planning is a broad term referring to strategies that increase women’s safety by increasing situational awareness of IPV-related risks and empowering women with necessary skills to enhance safety (Wood et al., 2019). The process involves gathering relevant information, evaluating the current situation of a survivor, identifying the types of advocacy and resources needed, and developing a plan to prevent and address IPV (Kahraman, & Bell, 2017). Survivor-centered safety planning would, for instance, recognize that survivors of IPV may not want to leave or may be unable to leave an abusive relationship and provide appropriate options to enhance safety even while staying in the relationship. Although women do not have control over the perpetrator’s behavior, they may be able to enact behaviors to enhance safety and minimize harm while in the relationship or when separated from the abuser (Wood et al., 2019).
Hamby (2014) discusses the importance of a strengths-based approach rather than a deficit-based approach to safety planning. Since women not only face threat to bodily harm due to IPV revictimization, but also face threat in other domains (e.g., financial well-being, stigma by the community, mental health), it is critical to take a holistic perspective in identifying women’s safety needs and understanding their protective strategies (Hamby, 2014). Women start the process of safety planning before coming into contact with an advocate, often with their first response to abuser-generated and life-generated risks. Abuser-generated risks include dangers other than physical violence including the effects of staying in or leaving their relationships. Life-generated risks are aspects of abused women’s lives over which they may have limited control, such as financial stress, discrimination, and overall health (Davies et al., 1998). Using a strengths-based approach, safety planning must involve understanding women’s perspectives about their situations, including their assessments of risks, past and current safety plans, and building a partnership with them to strengthen their safety plans (Davies et al., 1998).
Prior reviews either focused on safety strategies of women in abusive relationships or on effectiveness of broad IPV or advocacy interventions. For instance, an integrated review identified IPV-related safety strategies used by women in low-and middle-income countries. The identified safety strategies included engaging informal networks, minimizing the damage to self and family through enduring abuse, and building personal resources (Wood et al., 2019). Another review assessed the effects of advocacy interventions on IPV and well-being of abused women and found beneficial effects of intensive advocacy (12 hr of more) in addressing physical IPV at 12–24 months follow-up (Ramsay et al., 2009). Prior systematic reviews have not focused on effectiveness of safety planning interventions in reducing IPV among women, particularly marginalized women. Moreover, the reviews have not examined the inclusion and representativeness of marginalized women in safety planning intervention research in the United States.
Safety planning needs of marginalized survivors of IPV may differ from nonmarginalized survivors of IPV. For example, immigrant women face unique risks associated with their immigration status, social isolation, lack of knowledge of the U.S. system, and cultural background (Sabri, Nnawulezi, et al., 2018). In a qualitative study of safety planning needs of immigrant and refugee survivors of IPV, participants expressed the need to have a comprehensive approach to safety planning which included connecting survivors to resources for survival (e.g., emergency loans that do not need identification, orienting them on U.S. laws and rights, providing financial assistance to go back to the home country to get away from the abuser, and strengthening social support networks to address social isolation). Participants also expressed the need for culturally informed safety planning which involved consideration of survivors’ cultural background. For example, in some communities, women face abuse from both partners and in-laws. For these women, participants highlighted the need to consider additional safety planning around their families (Sabri, Nnawulezi, et al., 2018).
Given the impact of IPV on marginalized women and the potential difficulty that they face in accessing culturally relevant services, it is necessary to establish an evidence base for effective interventions that specifically address the safety planning needs of marginalized survivors of IPV. Therefore, the purpose of this systematic review was to (a) examine the existing research on safety planning interventions for inclusion and representation of survivors of IPV from marginalized groups, (b) identify types of interventions that incorporated safety planning and were successful in reducing the risk for future revictimization among survivors of IPV from marginalized groups, (c) examine elements of safety planning in effective interventions, and (d) describe challenges or limitations in safety planning intervention research with marginalized women. Marginalized women, in this study, were defined as women from minority racial/ethnic backgrounds, including U.S.-born minority women (e.g., indigenous women) as well as foreign-born immigrant women.
Method
A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (Moher et al., 2015). The following databases were searched in April 2020 for relevant studies: PubMed, CINAHL, EMBASE, PsychINFO, and Academic Search Ultimate. In the search process, the intervention related terms such as “intervention” or “program” were combined using the Boolean connector “OR.” The violence-related terms such as “Domestic Violence,” “domestic violence,” “domestic partner violence,” “family violence,” “dating violence,” “battered woman,” “battered women,” battered wife,” “wife beating,” “partner violence,” “marital rape,” “intimate partner violence,” “partner abuse,” “spousal abuse,” “spousal abuse,” “abuse,” “assault,” “trauma,” “spouse abuse”, “Spouse Abuse,” “spousal abuse,” and “abused spouse” were also connected using the Boolean connector “OR.” Terms related to safety planning in IPV interventions were also connected using the Boolean operator “OR,” such as “safety planning,” “safety planning intervention,” and “safety plan.” All of the intervention-related terms, violence-related terms, and safety planning–related terms were combined using the Boolean operator “AND.” Hand searching of reference lists of reviews of IPV interventions describing strategies for safety plans was also conducted. Although our search strategy and inclusion/exclusion criteria do not specifically include a focus on women from marginalized racial/ethnic groups, we pay special attention to this in our synthesis of studies.
Inclusion Criteria
Studies were included if they (1) were quantitative studies either using a randomized controlled trial or a quasi-experimental design; (2) reported elements of safety planning as part of the intervention; (3) evaluated the effectiveness of intervention on outcome of IPV including physical, sexual, and/or psychological abuse or other health outcomes in combination with IPV; (4) focused on adult women ages 18 years and older; (5) were conducted in the United States; and (6) were published in English. We did not place limitations on study time periods.
Exclusion Criteria
Studies were eliminated if (1) did not clearly report on elements of safety planning, (3) did not report results for violence as an outcome, (4) focused on participants under the age of 18 years, (5) exclusively focused on men or children, (6) were conducted in non-U.S. settings, and (7) were not published in English. All included articles were evaluated based on the criteria, and the authors discussed the evaluation criteria and resolved any disagreement in assessment method.
Results
Characteristics of the Included Studies
The initial search across the different databases identified 587 articles, with additional 51 identified through hand searching. After removing duplicates (n = 309), 329 abstracts and titles were screened for relevance. This screening resulted in 41 articles that were retained for full text review. Finally, based upon full text review, 17 studies were selected that evaluated interventions including safety plans, focused on reductions in IPV, and met the inclusion criteria identified above. Articles were also identified using reference lists of selected articles and are part of the final set of articles reviewed (Figure 1). Publication year of the selected articles ranged from 1999 to 2019. Two of the included studies used a quasi-experimental design, whereas the remaining used a randomized controlled trial design, with most using a usual care control group. The follow-up period ranged from 1 week to 24 months (Table 1).
Figure 1.
Prisma flow diagram for inclusion and exclusion of studies.
Table 1.
Summary of Intervention Characteristics.
| Author | Intervention Name/Type | Theoretical Model | Description of Intervention | Description of Safety Planning | Culturally Informed/Adapted | Control/Comparison Group | Study Design | Sample/Settings | Follow-Up Outcomes Assessed | Outcome Measure | Results | ||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Coker et al. (2012) | In-Clinic IPV Advocacy Intervention | Not reported |
Components:
Duration: Unclear Delivered by: Clinic-based IPV advocates |
Safety plans and referrals for desired legal, mental health, or advocacy services | Not reported | Usual care: Business card referral of their health care provider with the coalition hotline number | Quasi Experimental |
Eligibility regarding abuse: IPV within the past 5 years Sample size Total N = 231 Intervention group N = 138 Control group N = 93 Inclusion of minorities: 64% African American (intervention: 68.8% African American: control: 55.9% African American) Immigrant: NR Indigenous: NR Setting: Women presenting to a family medicine clinic |
Follow-up: 6, 12, 18, and 24 months Outcomes assessed: Help seeking, mental health, physical health, physical pain, medical visits, IPV exposure |
DAS WEB |
IPV scores trended toward greater decline among women in intervention relative to the control condition. Reduction in DAS scores associated with the advocate intervention was more likely to occur within the first 6 months of the intervention | ||||
| Gilbert et al. (2006) | Integrated Relapse Prevention and Relationship Safety Intervention | Empowerment theory Social cognitive theory |
Components:
Duration: Eleven (twice weekly for 6 weeks) 2-hr group sessions and 1 individual session Delivered by: Unclear |
Personalized safety plan generated from recovery and relationship check-ins |
Treatment content culturally specific to Black and Latina women | One session informational control condition—1 hr didactic presentation of a wide range of local community services, tips on help-seeking and a comprehensive directory of local IPV-related services (shelters, legal services, family and criminal court information on how to obtain order of protection) | RCT |
Eligibility regarding abuse: Abuse in prior 90 days Sample size Total N = 34 Intervention group N = 16 Control group N = 18 Inclusion of Minorities: 15.6% African American 59.3% Latina, 20.6% White (breakdown by assignment not reported) Immigrant: NR Indigenous: NR Setting: Methadone treatment program |
Follow-up: 3 months Outcomes assessed: depression, PTSD, sexual HIV risk, substance use |
Revised Conflict Tactics Scale-2 | Significant reduction in minor and severe psychological IPV at 3 months follow-up. No significant differences between the groups were found between the groups on sexual IPV or injurious IPV | ||||
| Gilbert et al. (2016) | WORTH and Traditional WORTH | Social cognitive learning theory Empowerment theory |
Components:
Duration: 4 weekly group sessions lasting 90–120 min Delivered by: 2 facilitators |
Participants developed a self-paced safety plan | Reported offering culturally tailored videos | Wellness promotion control arm
|
RCT |
Eligibility regarding abuse: No Sample size: Total N = 306 Computerized N = 103 Traditional: N = 101 Control group N = 102 Inclusion of Minority Women: 68% Black, 15.4% Latina, 16.7% Other Computerized: 70.9% Black, 14.6% Latina, 14.6% Other Traditional: 66.3% Black, 16.8% Latina, 16.8% Other Immigrant: NR Indigenous: NR Setting: Substance Using in Community corrections |
Follow-up: 6 months, 12 months Outcomes assessed: Re-exposure to IPV |
Revised Conflict tactics scale | Computerized WORTH reported significantly lower risk of physical IPV, severe injurious IPV, and severe sexual IPV at 12-month follow-up when compared with control. No significant differences were seen between Traditional WORTH and control participants for any IPV outcomes at 12 months post-intervention | ||||
| Glass et al. (2017) | Internet Safety Decision Aid | Not reported |
Components:
Duration: 1 session (time NR) Delivered by: Trained research assistants |
Tailored safety action plans based on participants’ risk level, priorities, and needs. Participants chose strategies to add to their safety plan and could print their feedback, safety plans and could access them anytime through the secured website | Recruitment materials and websites were offered in Spanish to cater to the language needs of monolingual Spanish speakers | Control website offered standard safety information and resources | RCT |
Eligibility regarding abuse: No Sample size: Total N = 721 Intervention group N = 357 Control group N = 364 Inclusion of Minority Women: 24.89% Black, 3.49% Asian, 1.60% Native American, 0.29% Hawaiian or Pacific Islanders, 0.87% Other, 5.09% Multiracial, 63.76% White Intervention: 27.35% Black, 3.70% Asian, 1.71% Native American, 0.28% Hawaiian or Pacific Islanders, 1.14% Other, 4.27% Multiracial, 61.54% White Immigrant: NR Indigenous: 1.60% Native American Setting: Computer |
Follow-up: 6 months, 12 months Outcomes assessed: Decisional conflict, Safety behaviors, and repeat IPV; secondary outcomes: depression and PTSD |
Severity of Violence Against Women Scale WEB |
Both intervention and control groups reported reduced psychological, sexual, and physical IPV at 12 months, but there were no significant differences between the groups | ||||
| Jack et al. (2019) | Nurse Home Visitation Program augmented with an IPV Intervention | Not reported |
Components: A standard nurse home visiting program was augmented with an IPV intervention. IPV component included universal assessment of safety, empathic response to IPV disclosure, risk assessment, discussion of safety options, assessment of readiness to address safety, awareness of IPV and its health effects, enhancement of self-efficacy, and system navigation which involved facilitating linkage to resources Duration: Unclear Delivered by: Nurses |
Assessment of stage of readiness to address safety, discussion of safety options, and system navigation identifying, referring, and facilitating participants’ access to services) | Not reported | Standard nurse home visitation:
|
RCT |
Eligibility regarding abuse: None Sample size Total N = 492 Intervention group N = 229 Control group N = 263 Inclusion of Minorities: 50.7% Hispanic/Latina, 23.3% Black or African American, 0.7%, 0.7% Asian, 1.4% American Indian or Alaskan Native, 0.2% Native Hawaiian or Other Pacific Islander, 5.9% multiracial, 62.8% White Intervention: 61.7% Hispanic/Latina, 16.2% Black or African American, 0% Asian, 1.5% American Indian or Alaskan Native, 0% Native Hawaiian or Other Pacific Islander, 5.1% multiracial, 68.5% White Immigrant: NR Indigenous: Yes; 1.4% American Indian or Alaskan Native Setting: Homes/Home visiting |
Follow-up: 6 months, 12 months Outcomes assessed: Quality of life; IPV recurrence, PTSD, depression, substance use, physical health, mental health |
Composite Abuse Scale | Both intervention and control groups reported reduced IPV but no significant differences | ||||
| Johnson et al. (2011) | Helping to overcome PTSD through empowerment (HOPE) | Cognitive behavioral | Components:
Psychoeducation about abuse and PTSD, safety planning, empowerment, establishing trust, managing triggers, etc.
Duration: 12 sessions twice weekly (1 −1.5 hr) over a maximum of 8 weeks Delivered by: Therapists with a minimum of a master’s degree in psychology or counseling and at least 1 year of prior experience working with traumatized populations |
Ongoing safety planning incorporated into the intervention (i.e., initial safety planning, with ongoing reevaluation and modification as needed) | Not reported | Standard shelter services:
|
RCT |
Eligibility regarding abuse: IPV 1 month prior to entering the shelter Sample size: Total N = 70 Intervention group N = 35 Control group N = 35 Inclusion of Minorities: 50% African American, 7.1% Other Race, 4.3% Hispanic, 42.9% Caucasian Intervention: 48.6% African American, 7.1% Other Race, 4.3% Hispanic, 48.6% Caucasian Immigrant: NR Indigenous: NR Setting: Women recruited from two inner city battered women’s shelters in a mid-sized Mid-West city |
Follow-up: 1-week, 3 and 6 months after leaving shelter Outcomes assessed: PTSD; depression: access to resources: social adjustment |
Conflict Tactics Scale 2 | Intervention groups were less likely to be re-abused over the 6 months follow-up period, when compared to the control group There were significant differences between the intervention and control groups |
||||
| El-Mohandes et al. (2008); Kiely etal. (2010) | DC-HOPE Intervention | Transtheoretical model of behavior change Dutton’s Empowerment Theory |
Components:
Duration: 10 sessions (35–45 min) Delivered by: Master’s-level social workers or psychologists |
Danger assessment to identify risks for harm and preventive options women might consider (e.g., leaving her partner, filing a civil protection order), and the development of a safety plan (e.g., leaving keys or paper documents with others) Take home tasks: safety plan such as discussing a code word with a trusted neighbor that would indicate that the woman was in danger and needed help |
Not reported; cultural considerations were indicated in training recruitment staff to be culturally sensitive | Usual care;
|
RCT |
Eligibility regarding abuse: IPV within the past year Sample size: Total N = 1,044 Intervention group N = 521 Control group N = 523 Inclusion of Minorities: 100% African American Immigrant; NR Indigenous; NR Setting: Women recruited from six community-based prenatal care sites (three hospital based) serving mainly minority women in DC between 2001 and 2003 |
Follow-up: Second and third trimesters of pregnancy (22–26 and 34–38 weeks of gestation respectively) and 8–10 weeks postpartum Outcomes assessed: IPV, smoking, depression |
Conflict Tactics Scale | The intervention improved outcomes in the intervention group and was more successful in resolving all risks including IPV risk Compared to control, women categorized with severe IPV in the intervention group showed a significantly reduced incidence of episodes postpartum. Women experiencing physical IPV in the intervention group were significantly less likely to experience episodes at first follow-up or at postpartum interviews compared with those in the usual care group. For women experiencing sexual IPV, the intervention did not significantly reduce their incidence of episodes at any follow-up visit during pregnancy or postpartum |
||||
| McFarlane et al. (2000) | Brief Intervention; Counseling Intervention; Outreach Intervention | Not reported |
Components: -Brief intervention: Wallet-sized resource card that included phone numbers of local agencies to assist with domestic violence including the police, legal aid, and the local women’s center
Delivered by: Female, bilingual Spanish-speaking, professional counselor with expertise in domestic violence and trained nonprofessional bilingual Spanish-speaking mother mentors who resided in the communities served by the prenatal clinics |
Safety was part of all three intervention arms | Cultural considerations were reported in translating study material in both English and Spanish Bilingual (Spanish/English) project counselor was able onsite at the clinic |
Quasi-experiment |
Eligibility regarding abuse: IPV in the year prior to or during thecurrent pregnancy Sample size: Total N = 329 Counselor group N = 98 Mentoring group N = 118 Control group N = 113 Inclusion of minorities: 96% Hispanic (predominately Mexican American) and about 90% indicated that they were monolingual Spanish speaking). Immigrant; About 90% indicated that they were monolingual Spanish speaking Indigenous; NR Setting: Two prenatal clinics of the health department of a large city in the southwestern United States |
Follow up; 2,6, 12, and 18 months postdelivery Outcomes assessed; IPV, use of community resources |
Severity of Violence Against Women Scale | Violence scores at 2 months postdelivery were significantly lower for the outreach group (p < .05) compared to the counseling only group, but not significantly lower than the brief intervention group. At 6-, 12-, and 18-month follow-up, there were no statistically significant differences among the intervention groups | |||||
| McFarlane et al. (2006) | Nurse Case Management | Dutton (1992) empowerment model |
Components: March of Dimes protocol with safety plan, supportive care, anticipatory guidance, and guided referrals Duration: 20 min Delivered by: Trained bilingual nurses |
15-item safety plan from March of Dimes protocol | Study material was available in both English and Spanish | Standard Care; Wallet-sized referral card-card lists a safety plan and sources for IPV services (shelter, legal, counseling, and police). No counseling, education, referrals, or other services were offered | RCT |
Eligibility regarding abuse: IPV within the past year Sample size: Total N = 319 Intervention group N = 158 Control group N = 161 Inclusion of Minorities: 27.9% Black, non-Hispanic, 59.6% Hispanic, 0.6% Other, 11.9% White Intervention; 23% Black, non-Hispanic, 67.1% Hispanic, 1.2% Other, 8.7% White Immigrant: 50.2% non-U.S.-born Intervention; 56.5% Indigenous; NR Setting: Clinics (urban) |
Follow-up: 6, 12, 18, and 24 months Outcomes assessed: Threats of abuse, assaults, risk for lethality, work harassment, safety behaviors, and use of community resources |
Severity of Violence Against Women Scale Danger Assessment Scale |
Both treatment groups of women reported significantly fewer threats of abuse, assaults, danger risks for homicide, and events of work harassment, but there were no significant differences between groups | ||||
| Mittal et al. (2017) | SUPPORT | Information-Motivation-Behavioral-Skills Model; Theory of Gender and Power; Transitional Family Therapy |
Components: Psychoeducation on family life cycle, recovery messages for positive changes and hope for future generations in individual sessions. In-group sessions, psychoeducation on STDs and HIV infection, IPV, safety, self-protection and choosing a healthy lifestyle Duration: eight weekly intervention sessions (three individual and five group) that were between 2 and 2.5 h long Delivered by: Experienced facilitators |
Developed a safety plan; details not included | Not reported | IPV reduction intervention developed by a local domestic violence agency-8 weekly group-based intervention sessions that were 1–1.5 h in length. The group intervention covered the following topics; (1) what is abuse?; (2) the abuse cycle; (3) the impact of abuse on children; (4) grief, fear, and guilt; (5) self-esteem and personal rights; (6) boundary setting and assertiveness; (7) setting realistic goals; and (8) healthy relationships and safety planning | RCT |
Eligibility regarding abuse: Physical, emotional, or sexual violence by any sexual partner in the past 3 months Sample size: Total N = 55 Intervention group N = 27 Control group N = 28 Inclusion of Minorities: 51% African American, 16% Other races, 33% White Intervention; 52% African American, 26% Other races, 22% White Immigrant; NR Indigenous; NR Setting: Community (Recruitment from multiple sites) |
Follow-up: Post-intervention 3 months Outcomes assessed: IPV; sexual behavior and safer sex communications; psychological antecedents of sexual risk behaviors; mental health; HIV knowledge; STD knowledge; HIV-related motivation, HIV-related behavioral skills; condom negotiating skills; depression; self-esteem; anxiety; PTSD |
Abuse Behavior Inventory; WEB | Compared to baseline, SUPPORT participants reported significant reductions in episodes of physical and psychological violence post-intervention and at 3 months follow-up | ||||
| Parker et al. (1999) | Empowerment protocol Only Empowerment protocol+ additional counseling |
Dutton (1992) empowerment model |
Components: Information on the cycle of violence: applying for protection orders, obtaining other legal help and other services. Development of a safety plan; women provided with a brochure. Half of the group received three additional counseling and information sessions to determine the sessions strengthened the intervention effect. Duration of empowerment protocol only: 30-min (10 min for protocol and 20 min for data collection) Delivered by: Trained nurses |
Developed a safety plan: securing and copying important papers; making copies of house and car keys; establishing a code with family and friends; hiding extra clothing, should a quick exit be necessary; and identifying behaviors of the abuser indicating increased danger, such as threats of murder or suicide | Not reported | Wallet-sized card with information on community resources for abuse, including the crisis hot line, the shelter, and law enforcement. No counseling, education, or advocacy was offered | Prospective cohort design with comparison group |
Eligibility regarding abuse: Only abused women who considered themselves still in a relationship (primarily because the abuser was the father of the baby) Sample size: Total N= 199 Intervention group N= 132 Comparison group N= 67 Inclusion of minorities: 35% African American, 33% Hispanic (primarily Mexican and Mexican American (breakdown by assignment not reported) Immigrant: Yes 33% Hispanic (primarily Mexican and Mexican American) Indigenous: no Settings Public clinics |
Follow-up: Post-intervention 6 months and 12 months postdelivery Outcomes assessed: IPV |
ISA Severity of Violence Against Women Scales |
Significantly less violence reported by women in the intervention group than by women in the comparison group | ||||
| Sharps et al. (2016) | DOVE | Dutton (1992) empowerment model |
Components:
Delivered by: nurses, community health workers supervised by nurses |
Safety planning information tailored to the context and level of danger | Not reported | Usual care:
|
RCT |
Eligibility regarding abuse: Experiencing perinatal IPV violence currently or in the year before pregnancy Sample size: Total N = 239 Intervention group N = 124 Control group N = 115 Inclusion of minorities: Intervention: 54% African American: 55% White non-Hispanic, 14% Other, 1% Missing Immigrant: NR Indigenous: NR Setting: In-person home visiting |
Follow-up: 1,3,6, 12, 18, and 24 months postpartum Outcomes assessed: IPV exposure, depressive symptomology in perinatal period |
Conflict Tactics Scale 2: WEB | Women in the DOVE treatment group reported a larger mean decrease in IPV scores from baseline compared to women in the usual care group. There were significant differences between groups |
||||
| Stevens et al. (2015) | Telephone support services | Not reported |
Components: Assessment, educating women about resources; referrals to community programs, helped participants through problem-solving barriers to obtaining services, and provided social support. Duration; Initially designed to feature 12 phone calls with a total duration of 360–720 min over 6 months, TSS participants completed on average 4.7 calls (SD = 2.9 calls) with a total duration of 81.1 min Delivered by: Trained nurse interventionists |
NR | Not reported | Enhanced Usual Care | RCT |
Eligibility regarding abuse: IPV within the past year Sample size: Total N = 253 Intervention group N = 129 Control group N = 124 Inclusion of minorities: Intervention; 45% African American; 1.6% Hispanic; 1.6% Asian American; 5.4% Other/ multiracial, 46.5% Caucasian Immigrant; Not reported Indigenous; Not specified Setting: Pediatric Emergency Department (Recruitment) |
Follow-up: 3 months, 6 months Outcomes assessed: IPV, quality of relationship, mental health symptoms, physical health, perceived social support, effectiveness in obtaining community resources, adverse events |
Composite Abuse Scale WEB |
Both intervention and control groups reported reduced IPV but there were no significant differences between groups | ||||
| Sullivan and Bybee (1999); Sullivan (2003) | Community-based advocacy | ESID model |
Components:
Delivered by: trained paraprofessional advocates |
Safety plans were individualized on the basis of each woman’s history and circumstances | Not reported | Services-as-usual from the community | Longitudinal RCT |
Eligibility regarding abuse: Spent at least one night at shelter for women with abusive partners Sample size: Total N = 278 Intervention group N = 143 Control group N = 135 Inclusion of minorities: 45% African American, 7% Latina, 2% Asian American, Remainder Native American, Arab American, or mixed heritage, 42% European American (breakdown by assignment not reported) Immigrant; NR Indigenous; Remainder Native American, Arab American, or mixed heritage Setting Shelter (recruitment) |
Follow-up: 6 months, 12 months, 18 months, 24 months Outcomes assessed: Experience of violence by partners and ex-partners; psychological abuse; quality of life; depression; social support; effectiveness in obtaining resources; difficulty obtaining resources |
Modified version of the Conflict Tactics Scale | Women in the intervention group reported less violence over time. More than twice as many women receiving advocacy services experienced no violence across the 2 years post-intervention compared with women in the control services group |
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| Zlotnick et al. (2011) | Interpersonal Psychotherapy-based Intervention | Interpersonal Psychotherapy; Dutton (1992) and Herman (1992) Empowerment and stabilization model |
Components:
Delivered by: Trained studyinterventionists |
Participants were assisted with a safety plan | Not reported | Women in the standard care condition received the usual medical care provided for pregnant women at their clinic as well as the educational material and a listing of resources for IPV | RCT |
Eligibility regarding abuse: Past year IPV Sample size: Total N = 54 Intervention group N = 28 Control group N = 26 Inclusion of minorities: 11.1% Black, 42.6% Hispanic, 7.4% Other/Multiracial, 38.9% White Intervention: 14.3% Black, 42.9% Hispanic, 7.1% Other/Multiracial, 35.7% White Immigrant: NR Indigenous: NR Setting: Women recruited from three Rhode Island Sites: two primary care clinics and one private OBGYN clinic |
Follow-up: 4–6 weeks post-intake, 2 weeks postpartum, 3 - Months Postpartum Outcomes assessed: depression, PTSD, IPV |
Revised Conflict Tactics Scale | No effect on IPV during pregnancy or up to 3-month postpartum | ||||
Note. IPV = intimate partner violence; NR = not reported; PTSD = post-traumatic stress disorder; ESID = Experimental Social Innovation and Dissemination; ISA = Index of Spouse Abuse; DAS = Danger Assessment Score; WEB = Women’s Experience of Battering; DOVE = Domestic Violence Enhanced Home Visitation Program; WORTH = Computerized Women on Road to Health; TSS = Telephone Support Services; SUPPORT = Supporting Positive and Healthy Relationships.
Sample and settings.
Sample sizes in these studies ranged from 34 to 1,044 participants. Among marginalized populations, African American women represented the largest racial/ethnic minority group in almost all studies, with the exception of few studies which reported more than half of their sample was Hispanic or Latina (59–67.1%; Gilbert et al., 2006; Jack et al, 2019; McFarlane et al., 2006) or where all women were Hispanic or Latina (McFarlane et al., 2000). Immigration status was clearly reported in only one study; this research evaluated a nurse case management intervention and described that 57% of the women in the intervention group were non-U.S. born (McFarlane et al., 2006). Another study tested the effectiveness of an empowerment protocol among abused pregnant women reported 33% of the women in the study identified as Hispanic, primarily Mexican, and Mexican American. However, immigration status of the participants was not clearly indicated (Parker et al., 1999). Regarding Indigenous women, only a few studies reported including American Indian or Alaskan Native women. The percentage, however, was either very low (1.5%; Jack et al., 2019) or not clearly reported, with an intervention study reporting that the remainder of the sample was Native American, Arab American, or of mixed heritage (Sullivan & Bybee, 1999; Sullivan, 2003). Regarding eligibility, participants were considered eligible for these intervention studies based on recency of abuse (i.e., ongoing IPV to IPV within the past 5 years), with IPV not being an eligibility criterion in two studies, although an IPV outcome was included (Gilbert et al., 2016; Jack et al., 2019).
The interventions were implemented and evaluated in clinics (Coker et al., 2012; McFarlane et al., 2006; Parker et al., 1999), including prenatal clinics (McFarlane et al., 2000; Zlotnick et al, 2011) or community-based prenatal care sites serving mainly minority women (El-Mohandes et al., 2008; Kiely et al., 2010), domestic violence women’s shelters (Johnson et al., 2011; Sullivan, 1999, 2003) or participants’ homes during home visits (Jack et al., 2019; Sharps et al., 2016). Most interventions were delivered in-person individually (e.g., Coker et al., 2012; Johnson et al., 2011), except for two which either used a web-based platform (Glass et al., 2017) or provided individual telephone support (Stevens et al., 2015). Two others delivered the intervention in hybrid individual and group format (Gilbert et al., 2016; Mittal et al., 2017), one with both computerized and in-person components (Gilbert et al., 2016)
Measures used to assess IPV outcomes.
Most studies measured IPV outcomes using the Conflict Tactics Scales or Revised Conflict Tactics Scales (El-Mohandes et al., 2008; Gilbert et al., 2006, 2016; Johnson et al., 2011; Kiely et al., 2010; Sharps et al. 2016; Sullivan, 1999, 2003; Zlotnick et al., 2011). Other studies used the Danger Assessment (Coker et al., 2012; McFarlane et al., 2006), Women’s Experiences of Battering Scale (Coker et al., 2012; Mittal et al., 2017; Sharps et al., 2016), Severity of Violence Against Women Scale (Glass et al., 2017; McFarlane et al., 2000, 2006; Parker et al., 1999), Index of Spouse Abuse (Parker et al., 1999), Abuse Behavior Inventory (Mittal et al., 2017), or the Composite Abuse Scale (Jack et al., 2019; Stevens et al., 2015).
Types of Safety Planning Interventions
Of the 17 studies included in the review, 14 reported some positive outcomes (Table 2). Eight randomized controlled trials reported that the intervention reduced IPV with significant differences between the intervention and control groups (El-Mohandes et al., 2008; Gilbert et al., 2016; Johnson et al., 2011; Kiely et al., 2010; Mittal et al., 2017; Sharps et al., 2016, Sullivan, 1999, 2003). An additional two studies reported positive outcomes for reducing IPV over time but were limited by nonrandom assignment of women to a comparison group (Coker et al., 2012; Parker et al., 1999). Another study found significant differences between the intervention and control groups in reducing psychological IPV but not severe physical, sexual, or injurious IPV (Gilbert et al., 2006). Other studies reported improved outcomes in terms of reduced IPV across both the intervention and control groups, with no differences between groups (e.g., Glass et al., 2017; Jack et al., 2019; McFarlane et al., 2006).
Table 2.
Intervention Outcomes.
| Authors | Name of the Intervention/Category | Format | Marginalized Groups Included (Total Sample) | Settings for Delivery and Recruitment | Significance of IPV Outcome |
|---|---|---|---|---|---|
| Coker et al. (2012) | In-Clinic IPV Advocate Intervention | In-person (individual) | 64% African American | Clinics (Rural) | +a |
| Gilbert et al. (2006) | Integrated Relapse Prevention and Safety (RPRS) Intervention | In-person (group and individual) | 59% Latina, 16% African American | Methadone Treatment Program | +b |
| Gilbert et al. (2016) | WORTH-HIV and IPV Intervention | In-person computerized (individual and group-based) | 68% Black, 15.4% Latina, 16.7% Other | Substance Using in Community corrections | + |
| Glass et al. (2017) | Internet Safety Decision Aid | Internet/computer-based (individual) | 25% African American; 3.5% Asian; 1.6% Native American; 0.3% Hawaiian or Pacific Islander, 0.87% Other; 5.1% Multiracial | Online | +c |
| Jack et al. (2019) | Nurse Home Visitation Program augmented with an IPV Intervention | In-person home visiting (individual) | 51% Latina 23.3% Black 0.7% Asian, 1.4% American Indian or Alaskan Native, 0.2% Native Hawaiian or Other Pacific Islander, 5.9% Multiracial | Homes/Home visiting | +c |
| Johnson et al. (2011) | HOPE | In-person (individual) | 50% African American; 4.3% Hispanic; 7.1% Other race | Shelters | + |
| El-Mohandes et al. (2008); Kiely et al. (2010) | DC-HOPE Intervention | In-person (individual) | 100% African American | Community-based prenatal care sites (multiple site recruitment) | + |
| McFarlane et al. (2000) | Brief, Counseling, Outreach | In-person individual | 96% Hispanic | Prenatal Clinics | +c |
| McFarlane et al. (2006) | Nurse Case Management | In-person (individual) | 60% Hispanic; 28% Black and non-Hispanic; 0.6% Other | Clinics (Urban) | +c |
| Mittal et al. (2017) | SUPPORT (IPV-HIV intervention) | In-person (individual and group) | 51% African American; 16% Other Races | Community (recruitment from multiple sites) | + |
| Parker et al. (1999) | Empowerment protocol | In-person (individual) | 35% African American; 33% Hispanic, | Public Clinics | +a |
| Sharps et al. (2016) | DOVE | In-person home visiting (individual) | 47.2% African American; 10% Other | Homes/home visiting | + |
| Stevens et al. (2015) | Telephone support services | Telephone-based (individual) | 48% African American; 1.6% Hispanic; 7% Asian | Pediatric Emergency Department (Recruitment) | − |
| Sullivan (1999, 2003) | Community-based advocacy | In-person (individual) | 45% African American; 7% Latina; 2% Asian; Remainder Native American, Arab American or mixed heritage | Shelter (Recruitment) | + |
| Zlotnick et al. (2011) | IPT-based | In-person (individual) | 43% Hispanic; 11.1% African American; 7.4% Other/Multiracial | Two Primary care clinics and one OBGYN clinic | − |
Note. IPV = intimate partner violence; IPT = interpersonal psychotherapy; HOPE = Helping to Overcome PTSD through Empowerment; PTSD = post-traumatic stress disorder; DC-HOPE = Washington DCHealthy Outcomes of Pregnancy Expectations; DOVE = Domestic Violence Enhanced Home Visitation Program; WORTH = Computerized Women on Road to Health; SUPPORT = Supporting Positive and Healthy Relationships.
Nonrandom assignment of women to comparison group.
Intervention significantly reduced psychological IPV but was not significantly different from the control group on severe physical, sexual, or injurious IPV, although it was 7.1 times more likely to report a decrease in severe physical IPV.
Both intervention and control groups reported reduced IPV but no significant differences.
Interventions with positive outcomes were categorized by the authorship team based on the inclusion criteria of the study sample, target of interventions, or types of interventions as conceptualized by the investigators of the studies referenced. The interventions are classified for clarity, although all interventions are not mutually exclusive. For studies focusing on IPV survivors with no other inclusion criteria besides the experience of IPV, the interventions were classified as advocacy-focused interventions as described by the study authors (i.e., in-person advocacy intervention, Coker et al., 2012; community-based advocacy, Sullivan & Bybee, 1999 Sullivan, 2003). When the inclusion criteria of the study sample were IPV as well as other clinical issues (e.g., substance abuse), and the intervention had an integrated psychotherapy component in addition to IPV and targeted IPV survivors with co-occurring health care needs, the interventions were classified as integrated interventions with a psychotherapy component. These integrated interventions were designed to address co-occurring health issues such as PTSD (e.g., Helping to Overcome PTSD through Empowerment [HOPE] intervention with a cognitive-behavioral therapy component for PTSD; Johnson et al., 2011), substance abuse and dependence (e.g., Integrated Relapse Prevention & Safety Intervention, for women recruited from a methadone treatment program, Gilbert et al., 2006), and HIV sexual risk behaviors (Supporting Positive and Healthy Relationships [SUPPORT] intervention with integrated IPV and HIV components; Mittal et al., 2017). Women recruited were those with health care needs such as clinically significant mental health symptoms (e.g., Johnson et al., 2011), substance use issues (e.g., Gilbert et al., 2006), and/or HIV sexual risk behaviors (e.g., Mittal et al., 2017). Interventions classified as empowerment interventions were those that described using an empowerment protocol (e.g., Parker et al., 1999), expansion of an empowerment protocol, and using empowerment theory (e.g., DC-HOPE intervention; El-Mohandes et al., 2008). Integrated interventions addressing empowerment along with mental health and other issues (e.g., HOPE; Johnson et al., 2011) and including psychotherapeutic approaches were classified under interventions with a psychotherapy component.
Advocacy Interventions
In the literature reviewed, three studies described their interventions as advocacy interventions (Coker et al., 2012; Sullivan, 2003; Sullivan & Bybee, 1999). Advocacy interventions are defined as those that provide advocacy services alone or in combination with other support for survivors or that use home-based or clinic-based advocates to administer an intervention (Ramsay et al., 2009). Positive outcomes were reported for two individual-level advocacy interventions. The first intervention involved clinic-based advocates to provide IPV support for women coming in for health care services (Coker et al., 2012). Women who screened positive for IPV were encouraged by the nurse to meet with the in-clinic staff advocate. This appointment focused on needs assessment, safety planning, education, support, and referral/facilitated linkage to needed resources. In this quasi-experimental evaluation study including mostly African American women, IPV scores in the advocate intervention clinics trended toward greater decline relative to the usual care clinics, with risk for lethality reduced within the first 6 months of the intervention among women experiencing current IPV at baseline (Coker et al., 2012).
Another 10-week community-based advocacy intervention (Sullivan & Bybee, 1999), based on an Experimental Social Innovation and Dissemination model (Fairweather & Tornatzky, 1977; Sullivan, 2003), used trained paraprofessional advocates to work one-on-one with women experiencing IPV (Sullivan, 2003). Trained undergraduate student advocates engaged in intense advocacy (4–6 hr per week for each woman, twice a week meeting), with women recruited from a domestic violence shelter. More than half of the women recruited belonged to racial/ethnic minority groups, mostly African American. The intervention strategies were assessing women’s situations, their social networks of support, and their unique needs and goals. For unmet needs, advocates worked with women to generate or mobilize appropriate resources and helped women devise safety plans when needed. These plans were individualized based on their relationship history, needs, and circumstances. Women in the intervention group experienced less IPV over time. Further, more than twice as many women in the advocacy intervention group experienced no IPV across the 2 years post-intervention compared to women who did not receive advocacy services (Sullivan, 2003; Sullivan & Bybee, 1999).
Empowerment-Focused Interventions
In the studies reviewed, the interventions that were described as using an empowerment protocol or its adaptation or developed from the Dutton’s empowerment model (1993) were identified as empowerment-focused interventions. Empowerment-based interventions facilitate survivor’s empowerment through information, knowledge, and awareness of community resources and by helping them identify their safety priorities. The interventions focus on moving survivors from a state of helplessness to enhancing their sense of control over their lives and attain their goals of safety (Cattaneo & Chapman, 2010; Dutton, 1993; Wood, 2014). Four studies assessed the impact of clinic-based individual empowerment-focused interventions. Almost all of these were evaluated among pregnant IPV survivors, with the exception of McFarlane et al. (2006) study which extended the application of the empowerment intervention to other abused women in primary health care settings. McFarlane and colleagues (2000) compared three individual-level interventions to address IPV among Hispanic pregnant women: (1) brief intervention (wallet size card with list of resources and information about personal safety), (2) counseling intervention (unlimited access to bilingual Spanish-speaking professional counselor in the maternity clinic), and (3) an outreach intervention consisting of the same unlimited access to the professional counselor plus the services of a nonprofessional Spanish-speaking “mentor mother” who resided in the communities served by the prenatal clinics. The mentor mother offered women support, education, referral, and assistance in accessing community resources through personal visits and phone contact. The outreach intervention was associated with a significant decline in IPV at 2 months post-delivery compared to the counseling-only group, but not significantly lower than the brief intervention group. According to the researchers, abuse screening by itself may be the most effective intervention to prevent future IPV among pregnant women (McFarlane et al., 2000).
An in-person individual intervention that was found to be effective in reducing violence over time was a brief, one-visit, 10-min empowerment protocol intervention conducted with abused pregnant women (33% Hispanic) in public clinics (Parker et al., 1999). Based on Mary Ann Dutton’s empowerment model (Dutton, 1993), the intervention educated women on the cycle of violence, provided information about community-based resources (e.g., information about hotlines and shelters), and how to obtain help such as applying for legal protection orders. Women were also provided with a brochure reinforcing the described information. The interviewer offered to assist with calls and act as an advocate if needed. Some women were also invited to attend three additional counseling and information sessions taught by workers at the local shelter. Women who received the empowerment protocol reported significantly less IPV than women in the comparison group who were only offered wallet-sized cards with a list of resources (Parker et al., 1999).
An adaptation of the empowerment intervention by Parker and colleagues (1999) was included in the IPV component of the DC-HOPE (Washington, DC, Healthy Outcomes for Pregnancy Education) intervention, which was a primary care behavioral counseling intervention for pregnant African American women. The intervention focused on multiple risks such as smoking, environmental tobacco smoke exposure, depression, and IPV. In the IPV component, a brochure was used to educate women about different types of abuse, the cycle of violence, and their danger levels in relationships based on scores on the danger assessment, preventative options, and provided safety plans. Women were also provided with list of community resources. The intervention was delivered by trained pregnancy advisors with master’s degree in counseling disciplines who provided individualized counseling with tailored approach to the multiple risks reported by each woman. The 8-session intervention was delivered prenatally (before or after prenatal care) for up to 45 min, with two post-partum booster sessions, reinforcing skills and goals, and adapted to specific post-partum stressors. Women’s progress was monitored for ensuring safety, in developing safety plans, and in considering options to remaining with partner (El-Mohandes et al., 2008; Katz et al., 2008). The intervention was found to be effective in improving all risks for pregnancy including IPV (El-Mohandes et al., 2008), including recurrent episodes of IPV during pregnancy and post-partum among African American women (Kiely et al., 2010).
Another type of empowerment-based intervention was home-visitation. The Domestic Violence Enhanced Home Visitation Program (DOVE; Sharps et al., 2016) was an empowerment intervention delivered by nurses or community health workers, 6 times within regularly scheduled nurse home visits, with three 15- to 25-min sessions occurring during pregnancy and three during the post-partum period. More than half of the women in the study belonged to racial/ethnic minority groups, particularly African Americans. The home visitors used a tablet or a brochure to educate women on IPV definitions and types, the cycle of violence, IPV during pregnancy, and the health consequences as well as conducted an assessment of risk factors for IPV using the Danger Assessment and provided information about community resources. The safety plans were individualized to each participant. Women in DOVE reported a larger mean decrease in IPV from baseline to follow-up than women in the control group. However, women with severe IPV or those with IPV were less likely to remain in the study than other women with less severe IPV or those without the abuser not in the home (Sharps et al., 2016).
Integrated Interventions with a Psychotherapy Component
Integrated interventions developed specifically for IPV survivors with clinically significant mental health issues.
Cognitive-behavioral and empowerment-based individual-level intervention.
Among interventions for IPV survivors with mental health symptoms, Helping to Overcome PTSD through Empowerment (HOPE), based on a cognitive-behavioral approach, was initially tested among women in domestic violence shelters. Most women in the study belonged to racial/ethnic minority groups, 50% being African Americans. The 8-week-long biweekly (1–1.5 hr) intervention included strategies such as the ensuring physical and emotional safety via safety check-ins and addressing symptoms, behaviors, and cognitions that interfered with intervention goals, quality of life, post-shelter goals, and safety. The sessions involved areas such as goal setting, psychoeducation about IPV and PTSD, safety planning, identifying threats to physical and emotional safety that were within women’s control, empowerment, cognitive restructuring, and establishing long-term support. Safety issues were prioritized within each session of HOPE. Women were also provided an “empowerment toolbox” including a list of positive coping strategies (e.g., safety behaviors, empowerment, managing symptoms, and improving relationships) to manage threats related to physical and emotional safety. The intervention was associated with significantly lower likelihood of re-abuse 6 months after leaving shelter when compared to women who received standard shelter services (Johnson et al., 2011).
Integrated interventions developed specifically for IPV survivors with substance use or both substance use and HIV risk issues.
Social cognitive learning and empowerment-based hybrid intervention.
A computerized hybrid (individual and group) intervention (Computerized Women on Road to Health (WORTH)) was found to be effective in significantly lowering the risk of physical IPV, serious injurious IPV, and severe sexual IPV at 12 months follow-up among substance using women in WORTH, when compared to women in the wellness promotion control group (Gilbert et al., 2016). Most women in the study were African Americans (76%), followed by Latinas (16%) and other races (18%). The intervention included computerized self-paced IPV prevention modules as well as four weekly group sessions, lasting 90–120 min. The videos and audio tools educated women about different types of IPV, trained women to identify IPV-related risks, provided feedback, and developed a safety plan. The computerized, interactive tool also assisted women in identifying resources including sources of social support. The intervention also focused on building negotiation skills, identifying IPV triggers for unsafe sex and drug use, and goal setting for IPV prevention (Gilbert et al., 2016). Like WORTH, the Relapse Prevention and Relationship Safety (RPRS) intervention (11 two-hr group sessions and 1 individual session) focused on promoting relationship safety and reducing drug use among African American and Latina women on methadone. More than half of the women in the RPRS intervention study were Latinas (59%), followed by 16% African American women. The intervention content was culturally tailored for African American and Latina women. The facilitators of WORTH raised awareness of the co-occurrence of IPV and drug use; assessed the level of danger in relationships; trained women in self-regulatory, communication, negotiation, and boundary-setting skills; reinforced self-efficacy; and focused on increasing women’s network of social support and their access to and utilization of services. The intervention was associated with a decrease in minor IPV (physical, sexual, psychological) and severe psychological IPV at 3 months follow-up (Gilbert et al., 2006).
Integrated Interventions Developed Specifically for IPV Survivors at Risk for HIV.
Information-Motivational-Behavioral Model, Theory of Gender and Power, and Transitional Family Therapy-Based Intervention.
The SUPPORT intervention based on Information-Motivation-Behavioral Skills model (Bandura, 1986; Fishbein, 2000), Theory of Gender and Power (Connell, 1987, and Transitional Family Therapy (Landau-Stanton, 1986) consisted of five group and three individual sessions between 2 and 2.5 hr long (Mittal et al., 2017). The IPV-focused sessions were delivered in a group format and included components such as education on healthy and unhealthy relationships and safety plans. Safety check-ins were conducted every week. Of the 55 women in the study, 51% were African American and 16% belonged to other racial/ethnic minorities. Compared to the control group, women in SUPPORT reported fewer episodes of IPV at follow ups in comparison to baseline (Mittal et al., 2017).
Elements of Safety Planning in Effective Interventions
Elements of safety plans of effective interventions included assessing individual needs and situations, educating women about types of IPV, helping women identify threats to safety, developing a concrete safety plan, facilitating linkage with resources and support services (Coker et al., 2012; Gilbert et al., 2006; Gilbert et al., 2016; Johnson et al, 2011; Kiely et al., 2010; Parker et al., 1999; Sharps et al., 2016; Sullivan, 2003; Sullivan & Bybee, 1999), providing advocacy services as needed (Sullivan, 2003; Sullivan & Bybee, 1999), and establishing long-term support with continued safety check-ins during intervention sessions (Johnson et al., 2011; Mittal et al., 2017). Empowerment was the focus with enhancement of safety behaviors and strengthening women’s support networks to manage threats related to safety (Johnson et al., 2011; Parker et al., 1999). Interventions also used cognitive restructuring and other psychotherapeutic methods to address mental health or trauma symptoms, substance use, and/or HIV risk behaviors, which interfered with women’s safety in relationships (Gilbert et al., 2006, 2016; Johnson et al., 2011; Mittal et al, 2017).
Limitations
This review only included studies conducted in the United States and those published in English. This precludes generalizability of the findings to safety planning intervention studies conducted outside the United States or reported in other languages. Second, almost all studies identified in the review did not exclusively focus on marginalized populations, which limited our ability to identify effective safety planning strategies specifically for marginalized women survivors of IPV. However, this review identifies a significant gap in the literature which is limited availability of evidence-based interventions for diverse groups of marginalized survivors. Finally, the choice of databases and interpretation of results were based on the judgment of the study team. Despite the limitations, the findings are informative for future researchers and practitioners developing, implementing, and evaluating interventions that address safety planning needs of diverse groups of IPV survivors in a variety of settings.
There were also limitations of the existing intervention research that highlight challenges in conducting intervention research for safety of survivors of IPV from marginalized groups. In this review, despite studies showing promising results for interventions in reducing IPV, there were limitations in study design and methodology such as small sample size (Coker et al., 2012; Johnson et al., 2011; Mittal et al., 2017), potential for selection bias due to less than 50% response rate for participation in the cohort study (Coker et al., 2012), low retention rate (e.g., retention rate ranging from 30% to 60% from 12 to 24 months follow-up; Coker et al., 2012), and nonrandom assignment of participants to the intervention and comparison groups (Coker et al., 2012; Parker et al., 1999).
Researchers often face numerous barriers in recruiting and retaining marginalized women survivors of IPV in intervention research. For instance, in the studies reviewed that included marginalized women, those who completed the screening and became eligible did not necessarily enroll in the study or may have refused to participate for fear of retaliation from their abuser (Parker et al., 1999; Sharps et al., 2016; Zlotnick et al., 2011), especially when the partner was present (e.g., for health care appointments in clinic-based recruitment; Zlotnick et al., 2011). In one study, only 36% of eligible women enrolled in the intervention trial (Jack et al., 2019). A significant proportion of women dropping out of the study between the consent process and further assessment prior to randomization is another barrier associated with high attrition rates in intervention studies (Zlotnick et al., 2011). Further, researchers may not be able to be reach out to eligible IPV survivors for safety reasons, complicating the ways in which women may be recruited, enrolled, or retained in studies. For example, the home visiting intervention studies can be limited by lack or limited engagement or retention of women who are experiencing higher levels of IPV and are currently living with the abuser (Sharps et al., 2016).
Some participants may not complete the minimum number of intervention sessions needed to see positive outcomes. For instance, in DC-HOPE, the minimum number of intervention sessions was delivered to only 59% of survivors of IPV (Kiely et al., 2010). In the SUPPORT intervention study, only 44% of the 27 participants completed five or more sessions in the eight-sessions intervention (Mittal et al., 2017). Even though some marginalized women may prefer face-to-face group interaction or may perceive benefits in participating in support groups of women in similar situations (Sabri, Nnawulezi, et al., 2018), in-person group-based interventions may be limited by barriers such as low attendance (Mittal et al., 2017), transportation issues, and limited time for self-care due to daily life stressors of marginalized women. In a feasibility and acceptability evaluation of a group-based intervention for African immigrant women by the first author, low attendance and adherence to the protocol was a significant barrier which led to the adaptation of the intervention into a remote technology-based format. Reasons for marginalized women dropping out of intervention studies after only completing some of the sessions or modules may purely be conjecture and more systematic investigations through follow-up studies need to be conducted to fully understand this dynamic.
While randomized controlled trials are considered the gold standard in intervention research, it may be more culturally appropriate to consider quasi-experimental designs combined with advanced statistical techniques or person-oriented qualitative approaches that focus on the lived experiences of marginalized women participating in interventions. Complicating this, there is a tension between building evidence within the traditional framework of scientific inquiry (including that which is prioritized by funding sources and academic journals) and the important work of understanding processes and outcomes of importance to marginalized groups. The difficult life experiences of women who are survivors of IPV are likely exacerbated by intersectional marginalized identities. This may make it difficult to maintain engagement in interventions, situate daily needs such as childcare and transportation needed for participation, and prioritize lengthy data collection activities. Attending to the basic needs of participants may facilitate the ability of some women to participate. IPV interventions must not focus on safety to the exclusion of women’s needs outside of their experiences of violence; it may be that needs such as employment, childcare, food, or housing security are more salient to survivors than reducing violence in their relationship.
Other barriers to participation may relate to safety planning interventions not being culturally informed or not designed accounting for diversity between and within racial/ethnic groups. Very few empirically supported interventions are culturally informed or include cultural values and strengths into interventions or account for contextual realities of minority women such as low socioeconomic status and minority group status (Sabri & Gielen, 2017). Further, marginalized women are often not engaged in the development of the intervention. In this review, cultural considerations in the design of the intervention content or culturally tailored content were part of the intervention in only two publications, both led by the same primary author (Gilbert et al., 2006; Gilbert et al., 2016). Other studies trained data collectors in cultural sensitivity (e.g., El-Mohandes et al., 2008; Kiely et al., 2010) or translated measures in non-English language (Glass et al., 2017; McFarlane et al., 2006, 2000). For instance, one study (Glass et al., 2017) considered language barriers faced by non-English speaking women in seeking IPV services and translated intervention material into Spanish. However, very few (11%) non-English speakers enrolled and participated in the study. This was despite the research team’s efforts toward use of multiple recruitment strategies for increasing enrollment of Spanish-speakers (e.g., Spanish-language radio, websites, community agencies). Technology-based interventions may address barriers marginalized women face in accessing in-person services such as transportation and social isolation. However, many marginalized women may have limited or no access to a computer, internet, and/or knowledge of available online IPV services. Linguistic adaptations may not result in culturally appropriate interventions; research should focus on including people from the groups of interest in intervention development and recruitment plans. Incorporating aspects of cultural humility across research may assist in intervention development and recruitment planning among marginalized groups (Tervalon & Murray-Garcia, 1998).
Further, recruiting marginalized women belonging to immigrant groups may also be challenging due to barriers such as immigration status, language issues, fear, stigma, misconceptions, religious barriers, limited understanding of the U.S. laws, and mistrust of researchers (Njie-Carr et al., 2019). In some more insular communities, there is also a fear of confidentiality being disregarded, therefore silencing voices of would-be participants (Center on Child Abuse and Neglect (CCAN), 2000). Additionally, for women who reside in some tribal communities, family members of the abuser may work in positions of power (i.e., the tribal police, tribal council, or at a local health clinic), making it a barrier to pursue interventions, justice, or services (CCAN, 2000). Additional research is needed on tailoring recruitment or intervention approaches for marginalized survivors of IPV (Glass et al., 2017). Further, researchers must work to build relationships and trust in communities that have been impacted negatively by research (Njie-Carr et al., 2019).
The findings of the studies in this review cannot be generalized to all diverse groups in the United States; this includes immigrant women, non-English-speaking women, indigenous women, and women in same-sex relationships. Regarding indigenous women in the United States, there are over 570 federally recognized tribes (National Congress for the American Indian, 2020), making it impossible to generalize these findings to different tribal groups. Further, the studies in this review included few minority/racial ethnic groups, with nearly lack of participation by immigrant and indigenous women in the United States. Further, majority of interventions were tested among women recruited via clinics or shelters, with clear gap in the literature on evidence-based interventions for addressing safety needs of survivors in nonclinical settings or those not seeking services. These limitations in design and methods highlight the need for rigorously evaluated culturally informed safety planning interventions for marginalized survivors of IPV, especially those in community settings.
Conclusion and Implications for Social Policy, Practice, and Research
This review highlights promising interventions with potential to enhance women’s safety. Effective approaches for safety are empowerment focused and culturally and contextually specific. The strategies include providing individualized intervention services, assisting women in identifying IPV-related threats to safety, developing tailored safety plans based on their priorities, facilitating linkage to needed resources, strengthening social support networks, and providing advocacy support when needed. Women with co-occurring concerns such as depression, PTSD, and drug use need integrated services to address these issues and to prevent these concerns from further placing women at risk for IPV. Continuous safety check-ins are critical to ensure women’s safety. This review also identified gaps in existing evidence-based literature on safety planning for IPV survivors. For instance, marginalized women at high risk for IPV-related homicides (e.g., immigrant and indigenous survivors) are underrepresented in existing intervention evaluations. To effectively address the safety needs of diverse marginalized survivors of IPV, interventions must be culturally informed, which includes conducting culturally responsive needs assessments, examining the impact of marginalized identities on survivors’ access to services, and providing culturally informed safety planning. This calls for additional intervention research studies, using rigorous designs, to provide empirical support for culturally informed safety planning interventions for marginalized survivors of IPV. This is especially needed for women who belong to groups that are underresearched and underserved in traditional IPV services. Studies are also needed to examine which safety planning strategies may be most effective for marginalized populations. Moreover, effective strategies must be in place to maximize recruitment and retention of marginalized survivors of IPV in safety planning intervention research to ensure their adequate representation in study findings. The strategies include engaging with the community, ensuring confidentiality and safety of research procedures, providing adequate incentives for survivors, using recruiters with similar background and experiences as potential participants (Hanza et al., 2016; Ibrahim & Sidani, 2014; Njie-Carr et al., 2019), and using peer-to-peer referrals (Evans-Campbell et al., 2006). All these efforts require strong collaboration among researchers and practitioners serving marginalized survivors of IPV. Practitioners need evidence-based approaches to provide effective services to marginalized survivors from diverse groups. Policy makers could use these findings to allocate funding toward research on developing and evaluating culturally informed interventions to prevent and address IPV-related issues among at risk groups of marginalized women.
Implications for Practice, Policy, and Research.
Existing literature is limited in guiding culturally informed interventions for diverse groups of marginalized women who are disproportionately affected by IPV.
Additional research is required to better address the safety planning needs of diverse groups of marginalized survivors.
Effective strategies must be in place for recruitment and retention of marginalized survivors to ensure their adequate representation in study findings.
Practitioners need evidence-based approaches to provide effective services to marginalized survivors from diverse groups.
Policy makers may allocate funding toward research on developing and evaluating culturally informed interventions to prevent and address IPV-related issues among at risk groups of marginalized women.
Critical Findings.
Additional research using rigorous methods is needed to establish an evidence base for effective interventions that specifically address the safety planning needs of marginalized survivors of IPV, particularly those who are underrepresented in the existing literature and are disproportionately affected by IPV.
There is need for more studies that use culturally informed approaches in design and evaluation of interventions for marginalized women.
Empowerment and advocacy are critical components of safety planning with survivors.
Interventions must include comprehensive risk assessments, examining the impact of marginalized identities on access and utilization of IPV services; providing tailored approaches based on survivors’ cultural backgrounds, priorities, and needs; facilitating linkage to resources; and conducting periodic safety check-ins.
Survivors with co-occurring mental health, substance misuse, and other issues need integrated care that could address co-occurring problems due to their potential to interfere with safety.
Acknowledgment
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Institute on Minority Health and Health Disparities (R01MD013863) and Eunice Kennedy Shriver National Institute on Child Health and Human Development (R00HD082350).
Author Biographies
Bushra Sabri, MSW, PhD, is an assistant professor at Johns Hopkins University School of Nursing. She has led or co-led multiple research projects focusing on risk factors and health outcomes of interpersonal violence across the life span. Her current research focuses on development and testing of trauma-informed culturally tailored interventions for survivors of gender-based violence from diverse racial and ethnic backgrounds.
Saraniya Tharmarajah, MSc, is a research assistant at the Evidence-Based Practice Center at the Johns Hopkins Bloomberg School of Public Health. Her research focuses on the translation of evidence into social interventions and public health policy to address racial and ethnic health disparities.
Veronica P. S. Njie-Carr, PhD, RN, ACNS-BC, FWACN, is an Associate Professor in the School of Nursing at the University of Maryland, Baltimore. Her research interests and scholarly activities address global health, HIV-related disparities, and intimate partner violence. She is committed to finding solutions to contribute to eliminating health disparities and propagating health equity.
Jill T. Messing, MSW, PhD, is an associate professor in the School of Social Work, Arizona State University. Her expertise includes intimate partner violence, domestic violence homicide/femicides, risk assessment, and interventions for survivors of intimate partner violence and criminal justice–social service collaborations.
Em Loerzel, MSW (White Earth Anishinaabe), is a social welfare doctoral student at the University of Washington in Seattle. Her current work and research involve intimate partner and sexual violence in the native community, sex trafficking of native women, and integrating Indigenous ways of knowing into classroom teaching and learning.
Joyell Arscott, PhD, is a HIV Epidemiology post-doctoral fellow at The Johns Hopkins Bloomberg School of Public Health. Her research examines the historical impact of social, structural, and institutional factors that contribute to the health inequities in marginalized populations, the impact of cumulative trauma on HIV risk and sexual decision-making for young adults and adults from underserved communities.
Jacquelyn C. Campbell, PhD, is the Anna D. Wolf Chair and Professor at the Johns Hopkins University School of Nursing. She has 30 years of experience in the area of violence against women with multiple studies of health consequences of intimate partner violence (IPV), as well as developing and testing culturally appropriate interventions for victims of IPV.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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