Introduction

Background

Physical or sexual violence by an intimate partner has been experienced by nearly 27% of women aged 16 and above globally (World Health Organization, 2021). The World Health Organization (2013) defines intimate partner violence (IPV) as ‘behavior by an intimate partner that causes physical, sexual, or psychological harm, including acts of physical aggression, sexual coercion, psychological abuse and controlling behaviors’ (p. vii). Experiences of IPV are associated with adverse physical, mental, sexual, and reproductive health outcomes including depression, sexually transmissible infections, unintended pregnancy, low birth weight and alcohol use (Muñoz et al., 2023; Ravi et al., 2022)

Intersectional scholarship recognizes that women can experience IPV in different ways due to overlapping systems of oppression that create unique experiences (Cardenas, 2023). In the United States, culturally and linguistically diverse (CaLD) women are reported to be disproportionately affected by IPV and report a higher lifetime prevalence compared with non-ethnic minority groups (Cavanaugh et al., 2014; Cho, 2012; Stockman et al., 2015). In New Zealand, findings from the New Zealand Violence Against Women Study indicated that women from some CaLD communities reported a higher prevalence of IPV when compared to other New Zealanders (Fanslow et al., 2010). However, it is important to note that the ability to accurately measure the prevalence of IPV in CaLD contexts is affected by factors including the language in which studies are conducted, small sample sizes, cultural differences in the conceptualization of IPV, and women’s reluctance to disclose experiences of IPV to cultural outsiders such as researchers (Vaughan et al., 2015).

Women from CaLD backgrounds who experience IPV may also encounter unique barriers to help-seeking. Barriers may relate to immigration concerns, limited knowledge of legal rights and available support, language barriers, fear and distrust of authorities, lack of cultural safety in available services, and social isolation (El-Murr, 2018; Maher & Segrave, 2018; Tayton et al., 2022). A systematic review has shown that screening conducted by health professionals can assist in identifying women experiencing IPV, particularly in the context of antenatal care, maternal health care, and emergency department presentations (O'Doherty et al., 2015). However, there is limited information on whether approaches to screening or risk assessment require adaptation to meet the particular needs of women from CaLD backgrounds.

Review Questions

The purpose of this scoping review is to collate available literature on approaches to screening and assessing CaLD women for IPV in Australia, Canada, Ireland, New Zealand, United Kingdom and United States of America (USA), with a view to identifying examples of best practice and areas requiring further research. These six countries have been chosen on the basis of their socio-economic similarities, being high-income countries as defined by the World Bank (World Bank, 2021b) with a Universal Health Coverage Index (UHI) greater than 80 (Adnan et al., 2020) positive net migration rate (World Bank, 2021a), and where the majority of residents speak English as a first language (University of Sheffield, 2023).

The research questions guiding this review are as follows:

  1. 1.

    Which tools and methods have been used to screen CaLD women for IPV or assess their risk of IPV in Australia, Canada, Ireland, New Zealand, United Kingdom and USA?

  2. 2.

    What barriers and facilitators are associated with the use of identified tools and methods?

  3. 3.

    What evidence exists regarding the effectiveness and acceptability of the identified tools and methods for screening CaLD women for IPV or assessing IPV risk in Australia, Canada, Ireland, New Zealand, United Kingdom and USA?

Method

Search strategy

A scoping review methodology was adopted. Scoping reviews are considered ‘an ideal tool to determine the scope or coverage of a body of literature on a given topic and give clear indication of the volume of literature and studies available as well as an overview … of its focus’ (Munn et al., 2018). As IPV is a rapidly evolving area of research, the review was limited to articles published (or, in the case of unpublished studies, written) since January 2012 to ensure that contemporary best practice was captured. Due to resource limitations (and given the focus on majority English-speaking countries) searches were limited to English-language studies.

Four allied health and medical databases were searched using a strategy combining keywords and data-specific subject headings relating to three concepts – namely, (1) IPV, (2) cultural and linguistic diversity, and (3) screening. Specific search strategies by database are presented in Table 1 and were developed in collaboration with a library information specialist.

Table 1 Search strategy, by database
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Additionally, websites of key organizations in the IPV sector in Australia, Canada, Ireland, New Zealand, United Kingdom, and USA were searched on 1 September 2022 to identify relevant grey literature and studies not indexed in the selected databases (Table 2).

Table 2 Sources of grey literature
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Screening

All results yielded from the database searches were exported into the reference management software EndNote (The EndNote Team, 2013) for deduplication using the steps outlined by Bramer and colleagues (2016). The deduplicated list of studies were then imported into the JBI System for the Unified Management, Assessment, and Review of Information (JBI SUMARI) (Piper, 2019) for title and abstract screening by two independent reviewers against the inclusion criteria set out below. An initial pilot test screen of 30 studies was conducted, consistent with best practice. Conflicts were resolved by an adjudicating reviewer and discussed to ensure that all reviewers had a consistent understanding of the inclusion criteria. Screening conflicts after the pilot stage were resolved by consensus. All studies identified for possible inclusion at title and abstract screening stage were then screened against the full text and reasons for exclusion were recorded.

Studies were included if they focused on women from CaLD backgrounds living in Australia, Canada, Ireland, New Zealand, United Kingdom or USA being screened/assessed in a health setting in relation to IPV. Key conceptual definitions are set out below and were used to guide screening decisions:

  • 1. Women: While it is recognized that people of any gender can experience IPV, epidemiological data demonstrate that women are disproportionately affected as a result of systemic gendered-power imbalances (Reed et al., 2010). The review therefore focused on studies involving participants who self-identified as women or, in the absence of information on self-identification, were described by the researchers as women. It is recognized that the concepts of sex and gender are distinct and that ideally research should report on both; however, the reality is that the terms are often used interchangeably in research (Day et al., 2016; Johnson et al., 2009). Accordingly, for the purpose of reviewing existing literature, any studies involving participants described as ‘female’ were eligible for inclusion unless the study indicated that the participants do not identify as women. No restrictions on age or sexuality were applied.

  • 2. Culturally and linguistically diverse: As recommended by Pham and colleagues in a recent review of the use of the term CaLD in Australian research, the descriptor was interpreted to mean people: (1) who were not born in English speaking countries (defined as Australia, the United Kingdom, Ireland, New Zealand, Canada, the United States of America and South Africa); and/or (2) for whom English is not the main language spoken at home but who do not identify as Indigenous to the country in which they live (Pham et al., 2021).

  • 3. Screening and risk assessment in a health setting: Screening was taken to refer to one or more tests or examinations offered presumptively with the aim of early detection and intervention to improve an individual's health outcomes (Speechley et al., 2017). Risk assessment was defined as the collection of information to assess clients’ likelihood of experiencing harm (Nathan & Bhandari, 2022). Studies were included if they examined screening and/or risk assessment tools (e.g., the procedures, tests and examinations used), and the methods by which those tools are administered; which includes the identity/role of the person conducting the screening, the medium by which it is conducted (e.g., face-to-face, online), and other factors including timing, language and setting. Only studies that focused on screening/risk assessment in health settings, including primary health care services, specialist services and hospitals were considered for inclusion. Studies in which tools and instruments were not administered by clinicians but were nevertheless used in a health setting were included if the purpose of the study was to assess the validity, reliability or appropriateness of screening/risk assessment items.

  • 4. Intimate partner violence: The World Health Organization (2013) definition of IPV was applied – namely, ‘behavior by an intimate partner that causes physical, sexual, or psychological harm, including acts of physical aggression, sexual coercion, psychological abuse and controlling behaviors’ (p. vii). This definition covers violence by both current and former spouses and other intimate partners’ and includes violence perpetuated by casual and non-legally recognized partners, including in the course of dating. For the purposes of this review, ‘sexual coercion’ and ‘controlling behaviors’ were interpreted to include reproductive coercion and abuse (Tarzia & Hegarty, 2021).

Data extraction and appraisal

After the screening process, a quality assessment was conducted to assess the risk of bias in eligible studies guided by the Joanna Briggs Institute Critical Appraisal Tools (Joanna Briggs Institute, 2022). These tools provide method specific checklists to assist in assessing the methodological quality of the included studies and examine the extent that bias has been addressed in the study design, conduct and analysis. The tools use a 10-item checklist to assist in appraisal. Studies are graded as either Yes, No, Unclear and Not applicable against each checklist item. From these results an overall appraisal is reached. Studies were not excluded as a result of the critical appraisal outcome; however, results were reported on and acknowledged when reaching conclusions.

Two reviewers independently completed data extraction of all studies. Data were extracted from included studies into the data extraction tool embedded in JBI SUMARI, comprising the following categories: (1) Country; (2) Setting/context; (3) Participant characteristics; (4) Outcomes measured; and (5) Description of main results relevant to the review questions.

Results

As shown in Fig. 1, a total of n = 1,320 results were yielded from the database search. After deduplication, the titles and abstracts of n = 846 studies were screened against the inclusion and exclusion criteria, resulting in n = 25 studies included for full text screening. A total of n = 5 studies were included in the final analysis. Study details are summarized in Table 3 and are discussed in detail below.

Fig. 1
figure 1

PRISMA flow diagram of search and final study selection

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Table 3 Characteristics of included studies (n = 5)
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Characteristics of the studies

Qualitative studies

Two qualitative studies were included in the review. One study was conducted in the United States (Messing et al., 2022). Participants were service providers who had worked for a minimum of two years with immigrant or refugee survivors or perpetrators of IPV providing healthcare, legal and social services (n = 57). Data were collected through focus group discussions and were used to develop guidance on how to use risk assessment tools. The second qualitative study was conducted in Australia. Participants were female midwives (n = 11) who had undertaken antenatal domestic violence assessment at a regional hospital in rural New South Wales serving a high CaLD and migrant population (Peters et al., 2022). Participants were aged between 24 to 60 years old and recruited via email sent to all hospital midwives. Participants engaged in semi-structured interviews in which they were asked about their perceived barriers to screening CaLD women.

Two tools were reported in the studies. Danger Assessment for Immigrant Women (DA-I) is used to assess risk of homicide by an intimate partner. The tool comprises 15 items derived from the original Danger Assessment tool, which has been tested for validity and reliability in other populations (Messing et al., 2022). An additional 11 items were added to assess whether the tool could identify IPV risk factors among immigrant women (Messing et al., 2022). Additional items used in the tool included questions related to whether client wished to complete the tool in English, had been prevented from attending school, job training or learning English, had been threatened to be reported to immigration or other services and whether the client’s partner was born in the US (Messing et al., 2022). The ‘Safe Start’ Program involves a series of admission questions for pregnant women presenting at an antenatal clinic of a regional hospital. The assessment asks domestic violence specific screening questions; if women are unable to answer at the first antenatal clinic presentation, this information is recorded into the electronic Maternity Information System (e-Maternity) and asked later in the pregnancy term (Peters et al., 2022).

Effectiveness of the Safe Start Program was attributed to the ease of the tool hosting platform, described by midwives as ‘user-friendly’ (Peters et al., 2022). Facilitators to administration of the DA-I discussed by Messing and colleagues (2022) included service providers fostering therapeutic relationships and trust with patients to create a safe environment for disclosure and risk assessment. Specifically, study participants highlighted the use of a conversational approach, carefully choosing words and asking open-ended, indirect and probing questions as behaviors that facilitate patients feeling comfortable to disclose experiences of IPV and assisting to gather information to assess risk. Furthermore, the effectiveness of tool administration was supplemented by the inclusion of patient education on IPV alongside screening, and collaboration between health services and safety planning that accounts for the social and cultural pressures women may face to keep their family together.

The studies identified several barriers to the use of the tools, among which language barriers were a key consideration. The barriers included differences in dialect (Messing et al., 2022; Peters et al., 2022), varying participant literacy (Peters et al., 2022), and instances where cultural perception influenced the interpretation of screening questions by the screening population (Peters et al., 2022). Furthermore, other communication barriers exacerbated the language barriers in both studies. For instance, in the study by Peters and colleagues (2022), midwives faced challenges such as short appointment time, limited opportunity to build rapport, and difficulties with the mode of question delivery (e.g., face-to-face or telephone). The study also revealed challenges with interpreters, such as issues related to gender, availability to attend sessions, and availability of language-specific interpreters. Additionally, Messing and colleagues (2022) discussed the issue of compromising client confidentiality through the involvement of language interpreters in sensitive conversations.

Both studies also examined the service providers' capacity to conduct screening/risk assessment, and highlighted several factors that hindered their ability to administer the tools effectively. These factors included insufficient confidence to conduct screening/risk assessment, inadequate training on how to conduct screening/risk assessment, and a limited understanding of cultural nuances, as identified by Peters and colleagues (2022). It was recommended that service providers build trust, relationships and rapport to better conduct IPV screening/risk assessment (Messing et al., 2022). Messing and colleagues (2022) suggest services that screen for or assess risks related to IPV should consider the context, language and safety of the client to ensure the best chance of engagement with the tool. Capacity building of those administrating the tool would also assist screening/risk assessment processes (Messing et al., 2022). Consistent with this recommendation, capacity building was suggested to help midwives feel more confident in administering the tool and working in cultural contexts (Peters et al., 2022).

Furthermore, the studies identified barriers related to the disclosure of IPV that were specific to the settings in which the screening or risk assessment took place. For instance, in the study that focused on healthcare, legal, and social services, Messing and colleagues (2022) discussed factors such as the impact of disclosure on immigrant status, fear of having their partner deported, and cultural appropriateness of the service where screening or risk assessment was conducted. Moreover, Peters and colleagues (2022) highlighted barriers to disclosure in the hospital setting, including a lack of continuity of care provided by midwives, which often resulted in poor rapport with the client, and the presence of family members such as children or partners during administration of the tool. To improve client engagement, Peters et al. (2022) recommended longer and more flexible appointment times, increased continuity of care, and the employment of bilingual workers and/or a specialized midwife to work with culturally and linguistically diverse populations.

Quantitative studies

All three of the included quantitative studies were conducted in the United States (Messing et al., 2013; Soglin et al., 2020; Soglin et al., 2021). Two of the studies included participants born in South Asia (specifically, India, Pakistan, Bangladesh, Sri Lanka, Nepal and Bhutan) (Soglin et al., 2020; Soglin et al., 2021) and one study included participants born outside of continental United States (of which 66.89% were born in the Caribbean or Mexico) (Messing et al., 2013). None of the quantitative studies collected data on participants’ sexuality and two studies did not collect data on the amount of time spent living in the United States since leaving their country of birth (Messing et al., 2013; Soglin et al., 2021). The one quantitative study that did collect data on years living in the United States did not report on these results (Soglin et al., 2020). All studies recruited participants aged 18 years or older with an age range across the studies of up to 74 years old.

The way in which IPV was conceptualized differed across the studies. Two studies defined IPV as a pattern of behavior used by an intimate partner to establish power and control over another person through fear and intimidation (Soglin et al., 2020; Soglin et al., 2021). This was described as occurring in many forms including emotionally abusive behavior, physical and sexual violence. By contrast, Messing and colleagues (2013), conceptualized IPV risk of homicide which was measured as having reported at least one experience of IPV in the previous six months and provided examples of severe IPV such as being beaten up, assaulted with a weapon or use of lethal violence.

Three tools were used to assess risk and/or screen for IPV – namely, the DA-I (described in 3.1.1 above) (Messing et al., 2013), the Index of Spouse Abuse (ISA) (Soglin et al., 2020), and the Southern Asian Violence Screen (SAVS) (Soglin et al., 2021). The ISA is a 30-item, 5-point Likert type self-report tool designed to assess physical, emotional, and sexual abuse through the two subscales of nonphysical (ISA-NP) and physical (ISA-P) violence. The ISA has been shown to be a valid and reliable tool to screen for IPV among various populations in health care settings in the USA and has been used as a gold standard to validate other screening tools (Cook et al., 2003; Hudson & McIntosh, 1981). However, this tool has also been adopted by researchers to measure the prevalence of IPV amongst study populations outside of clinical use in health care settings, as exhibited by Soglin and colleagues (2020). The SAVS is a 14-item screening tool for IPV based on the specific demographic and cultural issues affecting South Asian immigrant women in the United States. Items included in the SAVS included questions related to threatened deportation, being the last person to eat during meals, the use of burning or threatened burning as punishment and multiple questions related to the involvement of in-laws in abuse such as through denying access to valuable personal belongings (i.e., jewelry), and engaging in physical abuse (i.e., hitting, slapping, kicking) (Soglin et al., 2021). The DA-I was administered via bilingual (English and Spanish) structured telephone or in-person interviews to eligible women recruited at family courts, domestic violence shelters, community offices, public hospital and from domestic violence calls to the police (Messing et al., 2013). The ISA and SAVS were administered via face-to-face interviews to eligible women at a medical clinic, two community centers and a culturally specific intimate partner violence shelter for South Asian women (Soglin et al., 2020; Soglin et al., 2021).

While language barriers were cited in the administration of the ISA and SAVS, the issue was mitigated by having research assistants fluent in the language of participants or using a telephonic interpreter (Soglin et al., 2020; Soglin et al., 2021). Other observed barriers to tool administration included participant concerns about stigmatization, shame and fear of negative attention directed towards their community (Messing et al., 2013). Factors which were deemed to facilitate tool administration included participants’ perceptions that the tool was culturally competent (Messing et al., 2013) and having a completion time that is compatible for use in clinical settings (5 minutes) (Soglin et al., 2021).

With respect to the adequacy of the tools, Soglin and colleagues (2020) found the ISA to be a reliable tool for screening South Asian immigrant women in the United States but noted that ‘screening tools that address some of the cultural and demographic facets of [South Asian immigrant] IPV should be devised and tested to better serve this population’ (p. 708). The SAVS tool was developed in response and, when compared with the ISA-physical, the sensitivity and specificity were 0.96 and 0.87, respectively (0.94 and 0.92 for non-physical) (Soglin et al., 2021). The DA-I was also found to be a culturally competent tool that predicts risk for severe violence and re-assault for immigrant women with significantly greater accuracy than the original DA and women’s predictions of their risk of violence and injury (Messing et al., 2013).

Discussion

The dearth of studies on the use and effectiveness of IPV screening/risk assessment tools in CaLD contexts is a matter of concern. In the countries which were the focus of this review (Canada, Australia, New Zealand, United Kingdom, Ireland, and USA) migrants are estimated to comprise between 14% and 30% of the population (OECD, 2023). Given the documented barriers to migrant help-seeking in relation to IPV, screening and risk assessment have an important role to play in ensuring that women from CaLD backgrounds are linked into appropriate support services in a timely manner. However, as this review has demonstrated, there is very limited evidence to demonstrate that existing IPV screening and risk assessment tools and strategies meet the specific needs of CaLD populations. Based on the available data, it is not possible to definitively conclude that existing screening and risk assessment tools and methods are adequately sensitive to detect IPV in CaLD contexts, or that they are being administered in ways that are culturally safe and do not marginalize or stigmatize women on the basis of their ethnicity.

Four of the five included studies were conducted in the USA. However, the unique socio-legal context of each country and the way in which health services are structured and accessed may limit the generalizability of the USA-based studies. Moreover, two of the included studies collected data exclusively from South Asian women, and two collected data from health service providers only; this suggests the need for studies directly examining the experiences of women from other CaLD contexts. There is no universal experience of migrant womanhood; consequently, as Balaam and colleagues (2017) have noted, it is crucial to consider the heterogeneity of migrant women and their experiences, as their diverse backgrounds and circumstances may impact their care requirements.

Other intersectional factors warrant further investigation. For instance, none of the included studies collected data on the sexuality of the study population, notwithstanding a growing body of literature examining CaLD people’s experiences of IPV in the context of same-sex relationships (Workman et al., 2022). As Workman and colleagues (2022) note, people from CaLD backgrounds who identify as lesbian, gay or bisexual may encounter a double-burden of stigma ‘due to the inherent heterosexist nature of domestic violence screening tools, which reinforce that only women can be victims at the hands of male perpetrators with the inherent assumption of whiteness as these tools fail to consider the nuances of diverse identities’ (Workman et al., 2022).

Additionally, none of the included studies reported time since migration despite the fact that social experiences and health outcomes for migrant populations have been observed to change over time (Blair & Schneeberg, 2014; Razum & Twardella, 2002). It is plausible that women who have lived in a country for several decades may have different attitudes to IPV and access to/knowledge of available services compared to newly arrived women. For example, while residency and vehicle ownership have been cited as barriers to migrant IPV help-seeking barriers in some contexts (Anitha, 2011), this was not the case in an Australian study of migrant women who had resided in Australia for an average of 17 years (Satyen et al., 2018). As such, it is important for length of residence to be reported in IPV screening studies to determine whether tailored approaches are needed for women at different stages of the migration journey.

Despite these research gaps, the review highlights four general principles to guide IPV screening and risk assessment of women from CaLD backgrounds – namely:

  1. 1.

    Where possible, IPV screening and risk assessment tools that have been adapted and/or validated for specific CaLD populations should be used.

  2. 2.

    If language barriers exist, consideration should be given to using translated self-administered tools or verbally administering tools via an interpreter; however, care should be taken in selecting interpreters with suitable characteristics (e.g., gender, dialect), and steps must be taken to protect client confidentiality.

  3. 3.

    Efforts need to be taken to build rapport and create culturally safe spaces for disclosure; this may include the provision of longer appointment times, utilization of trained peers/cultural workers, and a focus on continuity of care.

  4. 4.

    Resources should be invested to building service providers’ capacity, skills and confidence in screening for IPV in CaLD contexts through training and ongoing professional development opportunities.

However, the studies included in this review also demonstrate the need to address broader, systems-level factors to meet the needs of women from CaLD backgrounds affected by IPV. Reported barriers to disclosure in a healthcare setting included concerns around immigration status, experiences of social stigma associated with CaLD status, social isolation, and lack of awareness of rights and available services. The findings align with previous studies that have shown how structural vulnerabilities, such as inadequate access to housing alternatives, economic instability, lack of social support, and limited social engagement, can affect migrant health outcomes and help-seeking behaviors (Evangelidou et al., 2023). The results indicate that efforts to enhance screening and risk assessment tools and health providers' proficiency in addressing IPV must be coupled with more comprehensive reforms to increase the level of support and social connectivity migrant women experience with their country of residence.

While the primary objective of this scoping review was not to appraise the quality of the evidence, it is necessary to address some quality issues when interpreting the results of this review. Specifically, the generalizability of the findings of included studies was limited due to: convenience sampling of study population from a single city (Soglin et al., 2020); small sample size (Messing et al., 2013; Soglin et al., 2021); and purposive, non-probability sampling (Messing et al., 2022). Additionally, one study noted that the inclusion of a larger sample could have contributed to the reliability and external validity testing of the screening tool through testing the tool with different samples (Messing et al., 2013).

The limitations of this review predominantly relate to the decision to limit the search strategy to English language studies conducted in six high-income countries and published since 2012. As has been noted, ‘no review can provide an exhaustive list of the literature on a subject; instead, all reviews are necessarily “bounded” by factors including search strategy design’ (Vujcich et al., 2023, p.2). It is possible that relevant studies have been published earlier and/or in relation to other countries, and the findings in this review cannot be regarded as an exhaustive account of IPV screening studies conducted in CaLD contexts. Further reviews on the experiences of women from CaLD backgrounds living in other socio-cultural contexts are encouraged. Additionally, in searching for screening and risk assessment tools and methods, this review uncovered the use of screening tools in prevalence studies of IPV among CaLD women. Despite the application of screening tools (such as the ISA) to collect prevalence data occurring outside of a health care setting, such studies were included if the purpose was to assess the validity, reliability or appropriateness of screening/risk assessment items.

Conclusion

This scoping review represents the first attempt to summarize the literature on tools and methods to screen women from CaLD backgrounds for IPV and/or assess IPV risk in Australia, Canada, Ireland, New Zealand, United Kingdom, and USA. The findings of the review indicate that there are few studies in which IPV tools have been developed, tested, or adapted for CaLD contexts. Further research is necessary to investigate the IPV screening and risk assessment requirements of women from CALD backgrounds, with a particular emphasis on exploring intersectional diversity; this involves gathering data from women of varying sexualities, countries of birth and residence, as well as women at different points in their migration journeys.