Quality of studies

Thirty of the included articles were published in peer-reviewed journals (one publication was a full doctoral dissertation69). Across all studies, there was a statement of aims and design to either partially or adequately address the objective. All studies included a brief description of the participants, sampling and recruitment strategy, data collection and data analysis. There was transparent reporting of ethical issues. Several studies were unclear or provided only partial information concerning the data analyses.48 50 52 56 60 61 68 70 Eight studies reported incomplete or ambiguous findings not supported by evidence.46 48 59 61 65 66 68 69 Overall, drawing on CASP and CERQual criteria for methodological quality, we assessed 1 study as having serious concerns,68 10 studies as having moderate concerns47–50 52 61 66 69 70 and the remaining 20 studies (which comprised the bulk of the studies) with no/very minor51 53–55 63 71 or minor concerns.25 44–46 51 56–58 60 62 64 65 67 72 73 Missing data may be attributed to word limits set by journals. Table 2 outlines the results of the CASP quality appraisal process and the corresponding rating used in the CERQual assessment.

Confidence in review findings

Using the CERQual approach, we assessed two review findings as high confidence and two review findings as moderate confidence (see table 3 for a summary of review findings and explanation for each CERQual assessment).

Key themes

Four analytical themes were developed that describe women’s experiences and expectations after disclosure of IPA to an HCP: (1) connection through kindness and care; (2) see the evil, hear the evil, speak the evil; (3) do more than just listen; and (4) plant the right seed. Each of these themes is described in detail as follows, with supporting quotations taken from the included articles. Table 4 provides a summary of analytical themes, HCP actions and emotional impacts on women if these key expectations are absent from care.

Connection through kindness and care

A major finding of this meta-analysis was that kindness and care were central to women’s expectations of HCPs after disclosure of IPA.44–47 51 52 56 57 61 67–73 The emotional support that women wanted from HCPs was described as ‘feeling cared for’44 71 and being ‘taken care of, physically and emotionally’.52 Two quotes below illustrate the importance of emotional support:

I just cried. I was just so relieved that somebody, somebody just said something. And he gave me the box of tissues and I just sat and cried and cried and cried. And he said ‘tell me when you’re ready’. And he was just the nicest person to me ever.56 (pe153)

What I wanted was someone to sit on my bed and tell me that they understand, talk to me about some options that I may have had…and hold my hand.61 (p2258)

Alongside kindness and empathy, women highlighted the need for the HCP to foster a trusting relationship in order to facilitate open discussion.47 49 50 52 57 58 60 61 64 65 68 69 72 73

…When you feel comfortable then you can talk about anything.58 (p618)

Developing a trusting relationship with the HCP had the potential to ameliorate some of the effects of the perpetrator’s psychological abuse.

It’s hard to take help when you’ve been in a situation, because your man will say ‘You can’t cope; don’t do this, don’t do that, don’t speak to strangers, don’t discuss our business’. They (partners) drum into you not to talk about it… But if you get that wee (little) trust in someone and that someone takes a wee bit of time with you – that goes a long way.65 (p38)

HCPs could foster trust by treating women with respect at all times. As one participant put it:

I can understand what you tell me. Talk to me intelligently and don’t treat me like a mushroom and answer my questions.49 (p1161)

Just sit there and maybe just listen to a few words that they’ve got to say. Are they hungry? Do they want a cup of tea? And respect them for who they are … They (women) actually want respect, respect, respect.73 (p194)

The absence of empathy, kindness, trust and respect had a negative emotional impact on women. Some reported feeling dehumanised, traumatised, and untouchable.

When I was talking with the psychiatrist, being diagnosed and prescribed medicine, I felt that he saw only my symptoms. It didn’t seem like one human being talking to another. It was a tough experience for me.69 (p65)

I understood on one hand that the doctor was there to do her job…(but) I think had she had a better bedside manner, that experience wouldn’t have been as traumatic… she just wasn’t very kind51 (p1173)

Helen recalled her desire to be ‘touched’ with compassion saying: ‘There was no feeling, there was nothing there. There was no interaction…everything is cold’. She noted that this accentuated her sense of being untouchable.61 (p.257)

Lastly, women appreciated ongoing, sustained engagement from their HCP.25 46 48 50 55 56 59 60 63 This could be achieved by the HCP subtly letting the woman know that they were available to help if she needed it. Specifically, women spoke of the need for continuity of carer—the same individual with whom they had built up a trusting relationship—rather than simply being able to access a particular service consistently.

…if I go in he (Doctor) says ‘is everything okay?’ and he will say, because he has met my new husband, he will say ‘he’s alright this one he is not as ugly as the last one is’. You know it is just like a nice conversation I think, and I think he says that in a way to let me know that I (the Doctor) am here if you want to talk about things, or I (Doctor) have not forgotten about what’s happened.55 (p.2371)

My children’s paediatrician knows about the abuse and always makes sure I am ok. I drive 30 min to see him, but I don’t want to switch providers.50 (p1216)

Women expected the HCP to understand that making change may take time, and to have patience with them:

Support has to go on… it gives you a chance to make mistakes.46 (p227)

Being unable to see the same practitioner left women frustrated and questioning the value of disclosing IPA in the first place. As a participant in a study by Spangaro and colleagues63 pointed out:

You get one lady that asks you about that type of stuff (IPA) and then you talk to that person and you go to your next visit but THAT lady has no idea and then you go to your NEXT visit and then THAT person has no idea. Yeah. It kind of loses track of why the lady asked the first time. (p346)

See the evil, hear the evil, speak the evil

This theme highlights the critical importance of HCPs recognising, validating and understanding abuse. Women emphasised the need for HCPs to make time to listen to them, even though they accepted that there were competing pressures and organisational barriers.25 46 51 57 61 64 69 72

The nurse who sat with me that day, she was lovely. She was really, really nice. She just listened. Sometimes it’s just nice to have someone to listen. I know that A&E staff are busy. I understand that. But I suppose when it’s a crisis you just need that, even if it’s just five min, just to let it all out.57 (p2322)

Women valued having someone to talk to about their relationship who would understand and really hear what they were saying.25 44 47 49 50 52 53 58–60 62–64 67–69 71–73 For South Asian ethnic minority women in a study by Ahmad et al,58 this meant being able to access a HCP from their own culture. In a study by Spangaro and colleagues,62 Australian Aboriginal women valued the opportunity to ‘yarn about it’ with HCPs from an Aboriginal-specific service (yarning is a form of storytelling). For others, it simply meant having someone who could see their perspective and understand the complexity of their situation. A participant in a study by Larsen and colleagues67 explained that the HCP made her feel that, ‘I see that I am understood and that I(will) get help and that I won’t be alone’. (p369) Similarly, women who received a paramedic-led mental healthcare intervention in rural Bangladesh valued the opportunity just to talk to someone:

I felt good talking, and afa (sister) listened to me, which helped me overcome my pain. … I don’t quite have people who I could open my heart to. … I found such a person and I talked, which made me feel great. … My heart felt light, and I had this good feeling even after I returned home.68 (p486)

When HCPs failed to make time for the woman or made it obvious that they were impatient with her for holding them up, it led to feelings of being unimportant and dismissed.

You tell a story that is so hard to tell; it is so difficult and ugly, and they (the healthcare professionals) do not even respect you enough to give you their undivided attention. They answer the telephone or keep looking at their watch; you can see it in their eyes that they are thinking about something else.64 (p953)

Most studies mentioned the importance of the HCP not only listening but believing, acknowledging and validating the woman’s experiences.25 47–49 51 53 55 56 59–61 64–67 69–73 Failure to validate women, suggested Keeling and Fisher,55 ‘feeds into the discourse of perpetrators, who often also claim that a survivor who chooses to disclose will not be believed’ (p2372). Indeed, Malpass and colleagues in their study of women’s help-seeking56 argued that validation may, in fact, be the ‘most important ingredient’ in the HCP response. When the HCP believed and validated women’s experiences, it could lead to an amelioration of shame and self-blame, reassuring women that what they were going through was not acceptable.48 60 65 66 One participant in a study by Bradbury-Jones and colleagues65 reported that

It’s really nice to hear somebody say ‘It’s not you. You haven’t done anything. It’s him (the abusive partner) – his behaviour is unacceptable’. (p38)

For some women, the HCP could play a role in validating their experiences by naming them as abuse.45 46 48 53 56 61–63 The process could sometimes be confronting, particularly when they had previously been in denial about what was happening in their relationship. A participant in Malpass’ study,56 for instance, described her fear and discomfort at having the HCP name the abuse, yet ultimately, she experienced this response as supportive.

I didn’t think that the problems that I have at home are domestic violence. I really didn’t … it’s so difficult to see myself in that position … because I see people (at work in the refuge) with their faces hanging off and that’s never happened to me. He’s pushed me a couple of times but never really hit me … bullying and God, controlling. He (the GP) put the label on which gave me a bit of a shock. But it also made me feel supported. (pe153)

Unfortunately, many studies described experiences where women received judgemental or blaming responses from a HCP after a disclosure of IPA. For instance, Örmon and colleagues71 reported that participants in their Swedish study were questioned by psychiatric care staff as to why they had not defended themselves from the perpetrator. Similarly, Kelly47 described women being told to ‘just leave’. These responses were interpreted by many of the study authors as being due to a lack of understanding on the part of the HCP with regard to the dynamics and context of IPA. The experience of being judged was repeated across countries and settings, with Reisenhofer and Seibold61 describing instances of nurses in an Australian emergency department context behaving in equally judgemental ways:

Participants felt blamed for ongoing violence for ‘choosing’ not to leave their abuser… Anna recalled one experience: ‘I could hear some of the (nurse’s) comments like ‘why would she do that to herself’, meaning you know, obviously why won’t she get out?’61 (p2258)

Older women in a US study by Zink and colleagues53 and a participant in a Jordanian study by Damra et al 25 also related similar experiences:

I did talk to one doctor years ago, and he advised me to leave, and I said I can’t. He said, well then you’ll have to suffer it out.53 (p902)

After he severely abused me, I decided to ask help from A & E department. When the staff came and started asking me about what happened, I felt that they were slowly withdrawing from helping and started asking about what I had done to make my husband angry and were totally focused on my physical injuries.25 (p812)

Having the HCP respond in a judgemental or blaming manner exacerbated women’s existing feelings of guilt at being abused.

…it’s making me feel bad about myself, I wasn’t doing it to myself.61

Many times, they (the healthcare professionals) make you feel guilty saying things out loud or sometimes it is even the way they look at you. … Once they even told me it was my own fault (that) he beat me up; that in one way or another, I deserved it.64 (p953)

Women also felt invalidated and doubted themselves when the HCP misunderstood or minimised the violence, particularly when they were experiencing psychological or other non-physical forms of IPA.

I still feel (that) many do not take it seriously, not even the medical staff…If you are not left black and blue or (do not) have physical injuries, (then) it feels that it does not count. As if you should be able to take a few bad words or insults because it is normal.64 (p952)

Do more than just listen

Although women greatly valued HCPs taking the time to listen and validate their experiences, a strong theme across the included studies was the need for HCPs to provide practical support.45–48 51 52 55 56 60 67 69 70 One woman described this as receiving ‘real help, not the kind that just passes you from one to another’52 (p723). In Kelly’s study of pregnant Latina women,47 one participant, Sara, described how HCPs assisted her with a range of issues, despite being ‘undocumented, uninsured, and Spanish-speaking’ (p.101):

When she arrived at the ED, pregnant and haemorrhaging from an assault by the abuser, she received prompt medical care. Sara experienced the nurses and doctors as very caring and concerned about her. She was given free medical care and information about applying for Medicaid. She was referred to an advocate who assisted her in obtaining a restraining order. She was referred for prenatal care.47 (p101)

Specific ways that women wanted to be helped by HCPs included addressing co-occurring health issues,45 49 53 67 documenting and describing physical injuries to assist with court cases46 48 60 63 67 and providing legal testimony.48 In Dienemann et al’s 2005 study of victim/survivors in the USA,46 they found that women also wanted

…documentation of any threats made by the abuser to the healthcare providers ‘You want it for the court situation and also from my own personal standing that I know that if it’s documented someplace that I didn’t just stand by and do nothing.’46 (p224)

Another key way that HCPs could provide practical support was through referrals and connection to other organisations and services within the broader community.44 46–48 52 54–56 59 65 67 72 Referrals were not restricted to IPA specialist organisations or refuges but could cover a whole spectrum of services. For instance, Jack and colleagues,59 based on their qualitative data, suggested that HCPs can assist women to ‘learn about and navigate health, social, education, childcare, employment, justice, domestic violence and housing services’ (p7). Watt and colleagues made a similar recommendation.52 Only four studies44 48 55 59 mentioned safety planning or risk assessments as a way HCPs could assist women.

Importantly, women across several of the studies identified an opportunity for the HCP to perform an advocacy role. For instance, in Dienemann et al’s study,46 this entailed making contact on behalf of women when an agency or service would not respond directly to her: ‘They never called me back. My doctor called and they did call him back’. (p226) Based on interviews with women in Canada, Narula and colleagues60 concluded that

…Many women felt very appreciative of the effort their physicians made to advocate for them by means of supporting insurance and disability applications, finding alternative housing, providing medical leave and support in legal cases in the form of clear documentation in their patient chart. (p597)

When HCPs failed to advocate on women’s behalf, this led to feelings of abandonment. For instance, in Nemoto et al’s study,70 a woman described how a nurse—with whom she had a good relationship—could have supported her during a meeting with a psychiatrist and her abusive ex-husband, but instead chose to keep silent:

During the meeting, she felt ill-treated by the psychiatrist, who saw her as ‘a crazy person who needed medicine to shut up.’ The nurse, however, kept quiet the entire time, which she felt was not helpful. She said that she would have liked the nurse to advocate for her in front of the physician and her husband by explaining that she was not crazy but was just tired. (p298)

Similarly, mismatches between women’s needs and the responses they received from the HCP caused frustration and disillusionment.25 47 54 55 60 61 67 69 70 73 In these situations, women felt that they had taken a risk to disclose to the HCP only to be left with a feeling of ‘coming up empty’.47 Even if the HCP was empathetic and listened without judgement, providing an inappropriate response was still perceived as a disappointment.63 For example, women across several studies mentioned being prescribed medication to treat their mental health issues, without the HCP attempting to address the underlying IPA. The excerpt from a study of women’s help-seeking pathways by Evans and Feder54 highlights this:

All but four of the disclosing women (n=16) said their doctor listened and was empathetic, but in most cases prescribed antidepressants and took no further action. Women did not find this supportive and few of them took the medication. This experience set up a cycle of disillusion where further consultation was not considered helpful and disclosing abuse seen as a waste of time. (p69)

Planting the right seed

The importance of the HCP facilitating choice and control for women, without feeling compelled to ‘fix’ their problems was emphasised.45 47 48 73 Women felt strongly that they were the agents of their own lives, and that the HCP’s role was to provide options, encouragement and support rather than dictating what actions they should take.45–48 52 54 62 64 66 67 One participant in Kelly’s47 study described this as ‘planting the seed’—priming the woman to be able to make her own decisions and take control of her own life and not badgering her with questions.

I am responsible for my own life. I choose what is good for me. I have been through enough with my husband, who tried to erase me. Here (with the HCP), I can be genuine and honest. I am not afraid of anything and that strengthens me. Here, I feel as though my life is my own and that I am the one to decide what I will do.66 (p403)

…Even if the choices aren’t that good, I still want a choice.51 (p1176)

Several studies touched on the challenges for HCPs in navigating the boundaries between advocacy and action, and empowering women to make their own choices.49 51 55 56 68 The power dynamic inherent in the medical encounter, for instance, was raised by Malpass and colleagues:

Some women ‘need that push from their GP’ to make contact with a DVA (domestic violence and abuse) advocate. This finding raises questions about shared decision making in the context of DVA and particularly how male GPs should skillfully manage the accentuated power imbalance in a consultation with a female survivor of DVA.56 (pe156)

Related to the concept of empowering women through giving her options is the idea that the HCP needs to respond according to the woman’s level of readiness and her individual circumstances.44–49 52 56 59 66 In other words, to continue the metaphor of planting a seed, the HCP must plant the right seed. This was reflected in ten of the included studies and was a strong theme across the data. Watt et al, who conducted vignette-based interviews with victim/survivors, concluded that:

IPV victims desire appropriate responses by health professionals, suitable to the woman’s stages of readiness for disclosure and accepting assistance…For IPV victims who disclose and are not ready to take action, informational support is important specifically when it is coupled with emotional support. IPV victims who disclosed and are ready for help need action undertaken with respect.52 (p724)

A participant in Spangaro’s study63 further explained this in the context of her interactions with a social worker:

The social worker asked me why I was still in contact with him, or if I was waiting for something from him and I said ‘Yes, just because I’m not ready to do anything more than this.’ It’s like—your personal—your emotional strength, you got like a limit and you just take care of yourself and the pregnancy. (p349)

When HCPs failed to understand or accept a woman’s level of readiness or the complexities of her situation, this led to frustration and a sense that the visit to the HCP had been a waste of time.

My GP asked if I can leave my home and go to a safer place… it is impossible to do that25 (p811)