2.1. BACKGROUND
In 2009, WHO hosted an expert working group to review experiences and evidence of implementing and evaluating health sector interventions for violence against women. An outline for guidance to the health sector on an appropriate response was drafted but consensus was reached that detailed reviews on various topics was needed before clinical and policy guidelines could be drafted. As part of this work, I was contracted to conduct a systematic review on the effectiveness of service delivery models of care for addressing intimate partner and sexual violence. I expanded this work in 2014 and included it as part of my thesis as it fitted well into the overall theme and provides a good perspective on health system issues.
The systematic review was included as a study in the thesis as it encompasses a more rigorous approach than a general literature review, which is prone to a number of potential biases, of which the greatest is selection bias. The systematic review methodology addresses these by clearly formulating a research question and using explicit methods for searching and identifying articles and analysing data. Literature reviews provide a summary and general understanding of a topic whereas systematic reviews provides detailed knowledge on a specific topic and provides evidence of effectiveness, which was the underlying subject of the thesis. For Study 1, some revisions were made to the typical criteria used in systematic review e.g. restrictions in terms of databases searched or study designs included as it was anticipated that there would be a lack of research in this field, and a greater attempt was being made to include work from LMIC.
2.2. QUESTION
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2.3. STUDY INCLUSION
The focus of this systematic review was on health system level programmes that were directed to female survivors of rape or IPV. Table 7 lists the criteria that were applied for the inclusion of studies. Articles in English, French, Spanish or Japanese were considered for review.
Table 7. Criteria for study inclusion
Criteria Requirements
Population Health organisations and health care providers who provide services to female survivors of rape or IPV
Intervention
Health systems level programmes providing services to female survivors of rape or IPV. This included:
Developing referral networks, i.e. health care providers at one service point referring patients to another service point, including community -based services.
Patients receive multiple services by multiple providers at the same site through internal referrals (horizontal delivery of services) or at one site (vertical delivery of services).
Individual providers are capacitated to offer more than one type of service
Making structural changes, such as changing documentation, reorganising services, changing rules within certain department, etc.
In the selected studies the latter two approaches occurred in programmes comprising of approaches that are described in the first two bullets and therefore these were not presented separately.
(Intervention that focused narrowly on screening, advocacy, counselling, or mental health interventions were excluded)
Comparator
Any comparison data were required. This included randomised controlled trials (RCTs), controlled trials, quasi-experimental studies, parallel groups, cohort studies, case-control studies, and pre-post intervention studies
Outcome
· Physical, psychological or reproductive health outcomes · Rates of rape or IPV recurrence
· Rates of providing related services · Referral rates
Timescale No restriction on time period for follow-up
2.4. SEARCH STRATEGY
The databases that were searched included EMBASE, Medline, Psych Info, CINAHL from 1st January 1990 to 17th November 2014, Criminal Justice, Global Index Medicus, Dissertation/Theses, Lilacs and WPRIM up to 28 June 2011, Psych Books and regional
80 databases (EMRO IMEMRO, SEARO-IMSEAR and AFRO-AIM) with no year limits. A WHO librarian undertook the search conducted up to June 2011 whereas I conducted the extended search up to November 2014. Terms used to conduct the searches comprised of rape and synonyms (e.g. sexual violence, sexual assault, sexual abuse, etc.), partner violence and synonyms (IPV, domestic violence, spousal abuse, battered women, etc.), any health - related setting (hospital, emergency department, clinic, etc.), health care, public health, and program/programme or intervention or health services.
Initially 26 645 potential articles and documents were retrieved through the search. N o systematic review was found that addressed the research question. Duplicate documents and those that were not on the topic were excluded from the initial search results, using specific search phrases and by reviewing each article title. Articles were omitted if they:
- Were purely descriptive
- Did not provide comparison data
- Were on inactivated polio vaccine or vaccination programmes - Focused on child or elder abuse
- Were based outside of the health care setting (police, court, prisons, shelters, community, etc.)
- Targeted the abuser or men as victims
- Focused narrowly on screening, advocacy, counselling, or mental health interventions
Eventually 869 articles and documents remained, and after a review of the abstracts 703 did not require a full review and were excluded. From the 166 publications that were revie wed, 11 published articles met the criteria of the search strategy.
2.5. QUALITY REVIEW
Although the intention was to apply the Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE) criteria (380) this was not applied
81 due to the poor quality of the majority of the limited publications addressing the research question.
2.6. DATA EXTRACTION AND SYNTHESIS
Two researchers including myself identified relevant publications and extracted the necessary data from the articles. This included information on the study design, setting, sample size, demographics of sample, intervention and comparator, follow -up period, and measures and results of outcomes. Using the extracted information, I synthesized the data to compile the results for the final review. This was done as a narrative based on tables that were drafted for each intervention according to the four outcomes defined in the research question. One study had two publications of varying follow-up periods but both were included as different outcomes that were relevant to the research question, were reported on (381, 382). A meta-analysis of outcomes could not be done due to the diversity of methodologies, settings, and interventions.
2.7. PROJECT MANAGEMENT
I was contracted to conduct the systematic review by WHO. At the time the research question and criteria had been defined but I reviewed this when I extended the search in 2014. I was assisted by a WHO librarian with the initial search but conducted this myself in 2014. Two additional researchers assisted me with the article identification and extraction of data. We met weekly during this period to discuss application of the criteria and selection of publications. If there were any uncertainties about the suitability of a publication, this was discussed at the weekly meeting and after all reviewed the publication a decision was made on whether to include the publication or not. I was responsible for the final synthesis and results.
82 The project timelines are presented below:
ACTIVITY PERSON TIME
Initial search WHO librarian June 2011
Initial identification of publications and data extraction
Ruxana Jina Jacqueline Mendes Leena Thomas
July – August 2011
Extended search Ruxana Jina November 2014
Identification of publications Ruxana Jina December 2014
Data extraction Ruxana Jina
Leena Thomas
December 2014 – January 2015
Data synthesis Ruxana Jina January – February 2015
Writing publication Ruxana Jina March 2015
2.8. LIMITATIONS
The intervention and health outcomes were not well defined in the original research question and although attempts were made to better define these, especially the model of care, some readers might disagree with these definitions or exclusion criteria. Moreover, these posed challenges with the search strategy and very broad search terms were used to be as inclusive as possible, which resulted in a large initial number of potential publications. Yet, it is possible that some studies may still have been missed. A meta -analysis could not be conducted which limited the reporting of results to a narrative form. Many of the articles were of poor quality and did not report detailed information on sample size, demographics, and measures of outcomes, amongst others. Efforts were made to include publications in other languages but some studies may have missed if the publication title or associated keywords were not available in English. All of the included studies were from HIC, which limit the generalisability of recommendations.
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3. STUDY 2: THE SEXUAL ASSAULT AND POST-RAPE CARE PRACTITIONERS