Understanding and reducing intimate partner violence perpetrated by men who misuse substances: the ADVANCE research programme

Background Despite the higher prevalence of intimate partner violence perpetration by men who misuse substances, the role of substance use in intimate partner violence is unclear. Evidence about what works to reduce intimate partner violence by men who misuse substances is lacking. Objectives To (1) understand the role of substance use in intimate partner violence perpetration, (2) develop a perpetrator intervention for men in substance use treatment and (3) test the feasibility and (4) effectiveness of delivering the intervention to men receiving substance use treatment. Design Objective 1: mixed-methods intervention development, including a qualitative meta-ethnography, narrative interviews with 14 men and their female (ex)-partners and a systematic review and meta-analysis of 9 perpetrator intervention trials. Objective 2: the ADVANCE 16-week group perpetrator intervention delivered in person, was developed and adapted for digitally supported remote delivery (ADVANCE-D) during the pandemic. Objective 3: a multicentre feasibility randomised controlled trial of ADVANCE plus substance use treatment as usual compared to treatment as usual only and a multicentre non-randomised controlled feasibility study of ADVANCE-D were conducted. Objective 4: a multicentre effectiveness and cost-effectiveness randomised controlled trial of ADVANCE was planned. Setting and participants Six community substance use treatment services in England (London, the West Midlands and the Southwest). Adult men receiving substance use treatment who had perpetrated intimate partner violence, their female (ex)-partners and staff delivering/supporting ADVANCE/ADVANCE-D delivery. Interventions The ADVANCE comprises 2–4 individual sessions and 1- to 2-hour weekly groups. ADVANCE-D includes 1 individual session, 7 fortnightly video groups and 12 website sessions, each followed by a coaching call. Main outcome measures The feasibility randomised controlled trial and non-randomised feasibility study measured eligibility, consent, recruitment, attendance (men) and follow-up rates and experiences of receiving or delivering ADVANCE/ADVANCE-D. These feasibility studies also assessed whether the following outcomes could be measured in a future effectiveness trial: intimate partner violence perpetration (men)/victimisation (women), substance use (men), self-management (men), and for men and women, mental health, health and social care service use, criminal justice contacts and quality of life. The primary outcome for the effectiveness trial was men’s self-reported intimate partner violence perpetration in the previous 4 months, 12 months post randomisation, using the Abusive Behaviour Inventory. Review methods Systematic searches of databases identified qualitative studies for the meta-ethnography and (non)-randomised controlled trials for the systematic review. Meta-analyses were conducted where comparable data existed. Study inclusion and data extraction processes were conducted as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results The meta-ethnography and narrative interviews identified the complex interplay between substance use and intimate partner violence perpetration in the context of intoxication, withdrawal, acquiring drugs, impact on relationships and wider dynamics of power, control and psychological vulnerabilities. Little evidence emerged for effective interventions to reduce intimate partner violence for men who misuse substances. Meta-analysis showed that integrated substance use and intimate partner violence perpetrator interventions were non-superior to substance use treatment as usual in reducing intimate partner violence (combined mean difference 0.1, 95% confidence interval 0.37 to 0.57; p = 0.68). One hundred and four men were randomly allocated to receive ADVANCE + substance use treatment as usual ( n = 54) or treatment as usual only ( n = 50), and at 16 weeks post randomisation, 49% (51/104) were followed up. Of (ex)-partners, 26% (27/104) were recruited and 63% (17/27) were followed up. Median rate of intervention session attendance was 28.6% (lower quartile 0 – upper quartile 50). Self-reported intimate partner violence perpetration reduced at follow-up among men allocated to ADVANCE (estimated group difference on Revised Abusive Behaviour Inventory: −1.31, 95% confidence interval −4.06 to 1.43). Progression to a definitive trial was supported, but the trial was suspended due to COVID-19. ADVANCE was adapted for remote digitally supported delivery. Of men screened to participate in the non-randomised controlled feasibility study of ADVANCE-D, 46% (57/125) were eligible and deemed suitable to participate by staff. Forty-five men were recruited, 40 were offered ADVANCE-D and 25 (25/45; 55.6%) were followed up. Of sessions offered, 68% of core sessions, 44% of website practice sessions and 33% of coaching calls were attended/completed. Mean number of sessions attended was 11.4 (standard deviation 9.1). Twenty-one (ex)-partners were recruited, and 11 were (52.4%) followed up. Reductions in intimate partner violence perpetrated or experienced were reported by 8/11 men and 17/25 women, respectively; however, outcomes measured lacked statistical power to show a difference. Limitations The COVID-19 restrictions precluded undertaking the randomised controlled trial. Conclusions Delivering ADVANCE and ADVANCE-D to men in substance use treatment services was feasible, acceptable and safe. Promising findings were reported. Definitive trials are needed. Future work Evaluation and implementation of ADVANCE and ADVANCE-D in other settings and populations will be considered. Trial registration The trial is registered as ISRCRTN79435190 and ISRCTN66619273. The review was registered in PROSPERO as CRD42107056596. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme (NIHR award ref: RP-PG-1214-20009) and is published in full in Programme Grants for Applied Research ; Vol. 13, No. 10. See the NIHR Funding and Awards website for further award information.