Effects of a Psychosocial Intervention among Pregnant Women Subjected to Domestic and Family Violence: A Pilot Randomised Controlled Trial from Nepal

Abstract

Domestic and family violence (DFV) against women is an important public health problem, placing significant health and economic burdens on individuals and families worldwide. The prevalence rates of DFV and its mental health sequelae are significantly higher in developing countries compared to developed countries, as women in these settings often lack resources to address DFV-related issues and improve their safety. Pregnancy is considered as a ‘window of opportunity’ to intervene against DFV. Psychosocial interventions that include the components to empower and provide psychosocial support to pregnant women exposed to DFV have potential to enhance their mental health and coping against DFV. This study aimed to develop and test a simple and brief psychosocial intervention targeting the mental health, self-efficacy, social support, and help-seeking behaviours of pregnant women experiencing DFV in Nepal. An assessor-blinded 1:1 parallel randomised controlled trial (RCT), with a nested descriptive qualitative study, was conducted to evaluate the effectiveness of the psychosocial intervention. A total of 140 eligible pregnant women were randomly assigned into two groups. Women allocated to the intervention group (IG) received a counselling session, an information booklet, and contact details of the counsellor. Women in the control group (CG) received a booklet, including a referral list of locally available DFV support organisations. Participants from both groups were interviewed three times using standard and valid questionnaires: the Hospital Anxiety and Depression Scale (HADS) for assessing anxiety and depression, the World Health Organization Quality of Life – Abbreviated Version (WHOQOL-BREF) for quality of life (QOL), the Medical Outcomes Study–Social Support Survey (MOS-SSS) short form for perceived social support, the Generalised Self-Efficacy Scale (GSES) for self-efficacy, and the modified safety behaviours checklist for the use of safety behaviours. Sociodemographic, obstetric, and newborns’ characteristics were also collected. Follow-up interviews were conducted at four to six weeks post-intervention (T1) and at six weeks after birth (T2). Generalised Estimating Equation (GEE) models with an intention-to-treat approach were used to assess changes in the outcome measures between the two groups over time. Data were analysed using the Statistical Package for Social Sciences (SPSS, version 25), and statistical significance was set at p < .050. During the follow-up interviews, intervention participants were asked about the strengths and weakness of the intervention, as well as recommendations on how the intervention could be improved for future use. In addition, seven purposively selected healthcare providers (HCPs) were interviewed to explore their perceptions regarding the intervention. Inductive thematic analysis was conducted to analyse the qualitative data. Out of 625 women screened, the lifetime prevalence of DFV was found to be 27.7% (n = 173). DFV in the last 12 months was significantly associated with mental health, QOL, social support, self-efficacy, and use of safety behaviours (p .050). Nearly 22.0% of women were lost-to-follow-up (LTFU) at T2, but baseline characteristics did not differ significantly between the participants who completed the study and those who were LTFU. Participants allocated to the IG showed significant improvements in anxiety (β = -3.24, p < .001) and depression (β = -3.16, p < .001) at T1. Such improvements were also sustained at T2 (p < .001). Similarly, significant improvements were seen in QOL at both T1 (β = 2.98, p < .001) and T2 (β = 2.45, p < .001) in the IG. There were greater increases in perceived social support and help-seeking behaviours in the IG compared with the CG at both T1 and T2 (p < .001). Thematic analysis of qualitative interviews identified ten themes which were grouped into three broad domains: i) DFV and its response mechanisms, ii) reflection on the program and its contents, and iii) recommendations for improving the intervention for future use. Participants were positive about the intervention and indicated that it improved their confidence and skills in managing stress. HCPs also supported the intervention; however, they suggested that for its successful and continual delivery in the future, additional infrastructure needs to be arranged in the hospital. Participants expressed that this intervention offered only a partial solution to the problem by addressing individual-level outcomes. This is the first known trial to test the effectiveness of a psychosocial intervention addressing mental health and safety needs of DFV victims in an antenatal setting in Nepal. The intervention was feasible to be implemented in an antenatal setting and showed promising effects on the mental wellbeing, perceived social support, self-efficacy, and help-seeking behaviours of DFV victims. Several avenues for further research are suggested, including expanding on the intervention to include family members, integrating the program into regular antenatal care, and conducting larger controlled trials with longer follow-up. Additionally, the findings underscore the pre-eminence of screening and managing negative emotional symptoms, such as depression and anxiety, among women experiencing DFV.