Domestic violence (also referred to as family violence) is a complex public health problem [1] that places a notable burden on the health care system [2]. The World Health Organization (WHO) defined domestic violence, an aggressive and oppressive form of interpersonal violence, as a situation where an individual uses control tactics to emotionally, physically, sexually, or economically abuse a family member or past/current romantic partner [3]. Forms of control behavior can include but are not limited to psychological, physical, sexual, financial, and emotional abuse [4].

The WHO commissioned a multinational study on domestic violence with data collected from 10 countries, which showed that 13%-61% of women between the ages of 15-49 years had experienced physical abuse from their intimate partners at least once in their lifetime [3]. However, due to various reasons including shame, embarrassment, social stigma, and fear of and dependency on the abuser, survivors are often unwilling to reveal their difficulties to others [5,6]. Domestic violence can have both short- and long-term effects on the mental and physical well-being of the survivors. Injuries and physical ailments resulting from prolonged exposure to domestic violence include chronic neurological disorders, cardiovascular diseases, respiratory, intestinal and digestive conditions, reproductive disorders, physical injuries, and even death [7-10]. The less visible, but equally detrimental, impact of domestic violence includes psychological and emotional sufferings, anxiety, fear, depression, and posttraumatic stress [11]. Survivors often require treatment and care from a spectrum of health professionals, ranging from family physicians to physical therapists or clinical psychologists [5].

By facilitating early detection and treatment through a well-structured system of education and support, health professionals could play an important role in promoting greater awareness on domestic violence, identifying survivors of violence, and enabling survivor protection [12]. As health professionals are usually the first line of contact for survivors, they would need to undergo special training to identify, support, and treat domestic violence patients. This would be of particular importance to conservative societies where domestic violence is known to be severely underreported [13,14]. Moreover, the immense shortage of health professionals worldwide, especially in developing countries [15], compounded by the lack of training of health professionals, poses immense challenges in tackling the global domestic violence crisis [13,16].

Occasional training programs on domestic violence consisting of seminars and workshops often claim poor retention rates, as they are mostly time-consuming [17], require health professionals to travel to training locations, and are taught by academics who themselves may have had little exposure to people who have experienced domestic violence [18,19]. With the increasing use of information communication technologies in health professions’ education, leveraging on digital education to provide domestic violence management education could help address the various challenges of training and manpower shortage while improving the cost-effectiveness of educational programs [20-22].

The term digital education refers to a range of teaching and learning strategies that utilize digital media and devices for training and as interaction tools [23]. Digital education can be further subclassified into various types according to delivery methods (online or offline), content, learning objectives, pedagogical approaches, and delivery settings [24]. The use of the internet to deliver content is referred to as the online mode of digital education, while the use of software or PowerPoint without the need for the internet to deliver content is referred to as the offline mode of digital education. With its scalability, flexibility, cost-effectiveness, and ability to overcome geographical and temporal constraints, digital education has the potential to provide more independent, customized, and accessible domestic violence training. Studies comparing digital education to traditional methods in various specialties including medical education and engineering have found digital education to be more efficient and effective in building knowledge [25,26].

Although a previous study reviewed domestic violence education among health professionals [19], digital education has been gaining popularity in health professions’ curricula and hence its use in domestic violence education should be studied further. To the best of our knowledge, there are no systematic reviews evaluating the effectiveness of digital health interventions specifically for domestic violence training among health professionals. Hence, the objective of this study was to evaluate the effectiveness of health professions’ digital education on domestic violence compared to that of traditional ways or no intervention.

The searches generated a total of 30,073 references. Following abstract and title screening, 144 articles were found to be relevant to domestic violence and selected for full-text screening. Of those, six met our eligibility criteria (Figure 1).

In this paper, we systematically reviewed and pooled data on the use of digital education for domestic violence management. We draw attention to the gap in digital education on domestic violence and the potential benefits of this educational strategy. Our findings provide preliminary evidence to show that using digital education to address socially sensitive issues such as domestic violence may improve certain educational outcomes in health professionals receiving the training. Although competencies, trustable professional activities, knowledge, skills, and attitudes do not automatically translate into change of practice, they are indispensable for improving patient outcomes.

All the studies included in this review were published after the year 2000, which is the period when digital education started becoming more prominent in health care professions’ education [51] and more laws were implemented to tackle domestic violence [5,52,53].

Interestingly, we found that in all the studies, the intervention groups had improved knowledge, skills, attitudes, and self-efficacy, even though the studies employed different methodologies, sample sizes, sampling periods, settings, and types of domestic violence education. Additionally, the changes in primary outcomes were observed within short time periods of up to 2 weeks after the intervention, with only one study [43] measuring retention at the 12-month follow-up. Although the variability suggests that digital education has the versatility to reach a wide range of health professionals in different populations and settings, it underscores the potential of homogeneous short-term digital interventions in improving the quality of care that these professionals provide.

Risk of bias was mostly unclear for blinding of outcome assessment and allocation concealment, but it was mainly low for sequence generation. While the nature of the interventions does not allow blinding of participants, we believe it would not have had any effect on bias risk. We minimized biases by having two reviewers independently assess the articles for inclusion, complete data extraction, risk of bias, and use of the GRADE criteria. The overall quality of the evidence was low or moderate due to the risk of bias and inconsistency across the studies (Table 3).

This review has some important strengths including a strict adherence to the gold-standard Cochrane methods and use of validated, comprehensive, and reproducible searches across seven databases. Our review adds to previous research on domestic violence education for health professionals, as it focuses on the use of digital education, which is a growing area of research. Some weaknesses have to be kept in mind when interpreting the results of this systematic review. For instance, although our searches were comprehensive, we cannot be certain that all relevant trials were included.

However, the evidence evaluated has some limitations. First, only a few studies were published in this area, and they were all from high-income countries, making generalizability challenging. Although digital education may potentially serve as an effective and impactful solution to educating health professionals in domestic violence management, applicability, scalability, and implementation in low- and middle-income countries have to be studied further [54]. Second, we acknowledge that in certain countries such as the United Kingdom, social workers are the first “line of response” to domestic violence. Third, only two studies [47,49] measured and reported learners’ satisfaction as one of the primary outcomes. This further highlights the need for uniform and validated outcomes and methods of measuring them to make conclusive judgements. Moreover, only two studies [43,47] used validated measurement instruments to measure outcomes, thereby making it challenging to compare the use of digital education between settings. Subsequently, the lack of data on retention rate, costs, or patient outcomes prevents policy makers from making informed decisions or assessing the transferability of digital education to other settings. Finally, none of the RCTs reported secondary outcomes such as patient outcomes, health professionals’ behavior change, and economic impact. Hence, we are unable to assess how these outcomes changed with digital education.

Future studies should be designed to evaluate the effect of digital education on these outcomes. We further recommend that future studies consider including other professionals such as social carers, psychologists, counsellors, or teachers. Findings of this review suggest that digital education could contribute to developing the competencies that health professionals need to respond to complex psychosocial problems such as domestic violence. Therefore, future studies should focus on recording more practical outcomes of the trainings such as change in detection and referral rates [55]. This will help ensure a better understanding of the actual value of integrating digital education modules into pre- and postregistration as well as the continuing professional development curricula. In addition, although domestic violence is more accepted and prevalent in low- and middle-income countries, the education gap is wide and digital education is still at the developing stage in these countries [14,56]. Data should be collected beyond geographical regions with inclusion of the cost analysis to obtain a better understanding of the impact and feasibility of integrating electronic learning modules on domestic violence management into the medical curriculum in low- and middle-income countries. We further recommend that future studies be designed with larger, appropriately powered RCTs, in both developed and low- and middle-income countries alike in order to ensure better representation. Researchers could use methods such as the Consolidated Standards of Reporting Trials for Social and Psychological Interventions 2018 (CONSORT-SPI 2018) checklist as guidance to design and report future studies on digital education for domestic violence in order to ensure that the data collected are of high quality and representative [57].

We believe that while digital education could help increase identification of and support to patients experiencing domestic violence, research with study designs incorporating blended learning might hold the highest potential. Such designs would combine the best of digital education, such as smartphones, apps, emails, text messages, and virtual patients, with the best of traditional classroom practices such as personalized contact or feedback, meetings, and discussions.

In conclusion, we found some promising, predominantly low-quality evidence for the effectiveness of digital education on domestic violence. We also highlighted the need for further research evaluating and validating culturally tailored digital education interventions geared toward more holistic management of domestic violence.