Improving the healthcare response to domestic violence and abuse in UK primary care: interrupted time series evaluation of a system-level training and support programme

Breaking the Silence: Addressing Domestic Abuse in Mental Health Settings-Identification, Screening, and Responding

Individuals experiencing domestic abuse (DA) struggle to disclose victimization, but as frequent users of mental health services, this is a pivotal setting for identification and addressing DA. This systematic review of 20 studies investigates DA identification, screening, and responses within mental health settings. Three databases were searched using these inclusion criteria: adults aged 18 and older accessing mental health services, samples comprising mental health professionals (or combination). No geographical restrictions were applied. All studies were peer-reviewed and published in English between January 2000 and December 2023. Studies had to incorporate screening for DA between (ex-)partners and/or response to disclosure within mental health settings. The findings revealed considerable variation in DA screening methods from direct screening tools to retrospective analyses of patient files. Professionals report barriers in identifying DA, including uncertainty about their role, time constraints, and the importance of building trust with service users. Nonetheless, many highlight the importance of routinely asking about DA. A small number of interventions have been effective in enhancing professionals' readiness to address DA, but it remains unclear what format of training is most effective. Service users report feelings of shame and fear of not being believed when disclosing DA, but are aided by therapeutic engagement and enhanced professional awareness. There is a lack of diverse inclusion in the research. In summary, there is considerable scope to develop good practice to support mental health professionals' ability to identify and respond to DA across assessment tool and training, but also in understanding what facilitates service users to disclose.

Addressing key risk factors for suicide at a societal level

A public health approach to suicide prevention recognises the powerful influence of social determinants. In this paper-the fifth in a Series on a public health approach to suicide prevention-we consider four major risk factors for suicide (alcohol use, gambling, domestic violence and abuse, and suicide bereavement) and examine how their influence on suicide is socially determined. Cultural factors and societal responses have an important role in all four risk factors. In the case of alcohol use and gambling, commercial entities are culpable. This Series paper describes a range of universal, selective, and indicated interventions that might address these risk factors, and focuses particularly on key universal interventions that are likely to yield substantial population-level benefits.

Healthcare professionals as domestic abuse survivors: workplace impact and support-seeking

BACKGROUND

Healthcare professionals (HCPs) are expected to identify and respond to domestic abuse (DA) among their patients. Although research suggests that a high proportion of HCPs are affected by DA, the impact of their experiences has been under-researched.

AIMS

To assess UK HCPs' experiences of DA and develop a broad understanding of its impact on work and HCPs' support needs.

METHODS

An online cross-sectional survey was promoted via multiple professional channels (October to December 2022). We adopted convenience sampling and analysed data descriptively.

RESULTS

Among the 192 HCP survivors who responded, all abuse subtypes-psychological, sexual, economic and physical-were common. Ninety per cent of abusers were male (ex)partners. Eighty-five per cent reported abusers directly interfered with their work and 92% reported their work and career were affected. Almost all reported physical and mental health consequences. Eighty-nine per cent reported their own experiences shaped their responses to patient survivors. On average, per year, HCP survivors reported they had 13 sick days, 5 days' leave, 10 days' lateness and 6 days' early departure due to DA. Only 20% reported their workplace had a staff DA policy, and over 50% were unsure what workplace support mechanisms were available. Just over half disclosed at work; concerns that others would question their fitness to practice were common. Twenty-two per cent reported aspects of work, for example, long hours, stopped them from seeking support outside work.

CONCLUSIONS

HCPs face unique barriers to DA disclosure and support-seeking and may benefit from tailored support from specialists who understand both DA and the healthcare context.

COVID-19 adaptations to a training and support programme to improve primary care response to domestic abuse: a mixed methods rapid study

BACKGROUND

Increased incidence and/or reporting of domestic abuse (DA) accompanied the COVID-19 pandemic. National lockdowns and enforced social isolation necessitated new ways of supporting victims of DA remotely. Identification and Referral to Improve Safety (IRIS) is a programme to improve the response to domestic abuse in general practice, providing training for general practice teams and support for patients affected by DA, which has previously been proven effective and cost-effective [1-3]. The COVID-19 pandemic required the adaptation of the programme to online training and remote support.

METHODS

This study is mixed methods rapid research, which aimed to gather evidence around the relevance, desirability and acceptability of IRIS operating remotely. Quantitative IRIS referral data were triangulated with data from four surveys and 15 interviews. Participants were local IRIS teams, IRIS-trained clinicians, and victim-survivors supported by IRIS services. The study was designed using the Lean Impact approach, allowing quick evaluation of innovation and the impact of social interventions. We carried out a framework analysis of the interviews, which is a qualitative methodology widely used in policy and applied research that enables research teams to move from descriptive accounts to a conceptual explanation of findings [4, 5].

RESULTS

We found that the adaptation to online training and support of IRIS was acceptable and desirable. Most clinicians felt confident addressing DA over the phone and online, although most were more confident face-to-face. While referrals to IRIS services initially declined in March 2020, numbers of referrals increased to pre-pandemic levels by July 2020. Patients felt well supported remotely, although patients who had previously experienced face-to-face support preferred it. Technology was the most frequently mentioned barrier to the change from face-to-face training and support to online training and remote support.

CONCLUSIONS

This study contributes to practice by asserting the desirability and acceptability of training clinicians to be able to identify, ask about DA and refer to the IRIS programme during telephone/online consultations. This is of relevance to health and public health commissioners when making commissioning decisions to improve the general practice response to domestic abuse.

Global Prevalence and Mental Health Outcomes of Intimate Partner Violence Among Women: A Systematic Review and Meta-Analysis

The aim of this systematic review was to assess the magnitude of the association between types of intimate partner violence (IPV) and mental health outcomes and shed light on the large variation in IPV prevalence rates between low- to middle-income countries and high-income countries. The study is a systematic review and meta-analysis. The following databases were searched for this study: Cochrane, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and the Applied Social Sciences Index and Abstracts. The inclusion criteria for this study are as follows: quantitative studies published from 2012 to 2020 on IPV exposure in women aged 16+, using validated measures. Random effects meta-analyses and subgroup analysis exploring heterogeneity across population groups in different economic contexts are used in this study. In all, 201 studies were included with 250,599 women, primarily from high-income countries. Higher prevalence rates were reported for women's lifetime IPV than past year IPV. Lifetime psychological violence was the most prevalent form of IPV. Women in the community reported the highest prevalence for physical, psychological, and sexual violence in the past year compared to clinical groups. Perinatal women were most likely to have experienced lifetime physical IPV. Prevalence rates differed significantly (p = .037 to <.001) for "any IPV" and all subtypes by income country level. Meta-analysis suggested increased odds for all mental health outcomes associated with IPV including depression (odds ratio [OR] = 2.04-3.14), posttraumatic stress disorder (PTSD) (OR = 2.15-2.66), and suicidality (OR = 2.17-5.52). Clinical and community populations were exposed to high prevalence of IPV and increased likelihood of depression, PTSD, and suicidality. Future research should seek to understand women's perspectives on service/support responses to IPV to address their mental health needs. Work with IPV survivors should be carried out to develop bespoke services to reduce IPV in groups most at risk such as pregnant and/or help-seeking women.

Recommendations for Canada's National Action Plan to End Gender-Based Violence: perspectives from leaders, service providers and survivors in Canada's largest city during the COVID-19 pandemic

INTRODUCTION

The Canadian government has committed to a national action plan (NAP) to address violence against women (VAW). However, a formalized plan for implementation has not been published. Building on existing recommendations and consultations, we conducted the first formal and peer-reviewed qualitative analysis of the perspectives of leaders, service providers and survivors on what should be considered in Canada's NAP on VAW.

METHODS

We applied thematic analysis to qualitative data from 18 staff working on VAW services (11 direct support, 7 in leadership roles) and 10 VAW survivor participants of a community-based study on VAW programming during the COVID-19 pandemic in the Greater Toronto Area (Ontario, Canada).

RESULTS

We generated 12 recommendations for Canada's NAP on VAW, which we organized into four thematic areas: (1) invest into VAW services and crisis supports (e.g. strengthen referral mechanisms to VAW programming); (2) enhance structural supports (e.g. invest in the full housing continuum for VAW survivors); (3) develop coordinated systems (e.g. strengthen collaboration between health and VAW systems); and (4) implement and evaluate primary prevention strategies (e.g. conduct a gender-based and intersectional analysis of existing social and public policies).

CONCLUSION

In this study, we developed, prioritized and nuanced recommendations for Canada's proposed NAP on VAW based on a rigorous analysis of the perspectives of VAW survivors and staff in Canada's largest city during the COVID-19 pandemic. An effective NAP will require investment in direct support organizations; equitable housing and other structural supports; strategic coordination of health, justice and social care systems; and primary prevention strategies, including gender transformative policy reform.

A Systematic Review of Culturally Competent Family Violence Responses to Women in Primary Care

Existing culturally competent models of care and guidelines are directing the responses of healthcare providers to culturally diverse populations. However, there is a lack of research into how or if these models and guidelines can be translated into the primary care context of family violence. This systematic review aimed to synthesise published evidence to explore the components of culturally competent primary care response for women experiencing family violence. We define family violence as any form of abuse perpetrated against a woman either by her intimate partner or the partner's family member. We included English language peer-reviewed articles and grey literature items that explored interactions between culturally diverse women experiencing family violence and their primary care clinicians. We refer women of migrant and refugee backgrounds, Indigenous women and women of ethnic minorities collectively as culturally diverse women. We searched eight electronic databases and websites of Australia-based relevant organisations. Following a critical interpretive synthesis of 28 eligible peer-reviewed articles and 16 grey literature items, we generated 11 components of culturally competent family violence related primary care. In the discussion section, we interpreted our findings using an ecological framework to develop a model of care that provides insights into how components at the primary care practice level should coordinate with components at the primary care provider level to enable efficient support to these women experiencing family violence. The review findings are applicable beyond the family violence primary care context.

General practice wide adaptations to support patients affected by DVA during the COVID-19 pandemic: a rapid qualitative study

BACKGROUND

Reporting of domestic violence and abuse (DVA) increased globally during the pandemic. General Practice has a central role in identifying and supporting those affected by DVA. Pandemic associated changes in UK primary care included remote initial contacts with primary care and predominantly remote consulting. This paper explores general practice's adaptation to DVA care during the COVID-19 pandemic.

METHODS

Remote semi-structured interviews were conducted by telephone with staff from six localities in England and Wales where the Identification and Referral to Improve Safety (IRIS) primary care DVA programme is commissioned.  We conducted interviews between April 2021 and February 2022 with three practice managers, three reception and administrative staff, eight general practice clinicians and seven specialist DVA staff. Patient and public involvement and engagement (PPI&E) advisers with lived experience of DVA guided the project. Together we developed recommendations for primary care teams based on our findings.

RESULTS

We present our findings within four themes, representing primary care adaptations in delivering DVA care: 1. Making general practice accessible for DVA care: staff adapted telephone triaging processes for appointments and promoted availability of DVA support online. 2. General practice team-working to identify DVA: practices developed new approaches of collaboration, including whole team adaptations to information processing and communication 3. Adapting to remote consultations about DVA: teams were required to adapt to challenges including concerns about safety, privacy, and developing trust remotely. 4. Experiences of onward referrals for specialist DVA support: support from specialist services was effective and largely unchanged during the pandemic.

CONCLUSIONS

Disruption caused by pandemic restrictions revealed how team dynamics and interactions before, during and after clinical consultations contribute to identifying and supporting patients experiencing DVA. Remote assessment complicates access to and delivery of DVA care. This has implications for all primary and secondary care settings, within the NHS and internationally, which are vital to consider in both practice and policy.

Preventing Gender-Based Homelessness in Canada During the COVID-19 Pandemic and Beyond: The Need to Account for Violence Against Women

The coronavirus disease of 2019 (COVID-19) pandemic has led to increases in intimate partner violence (IPV), a leading cause of women's homelessness. Although the Canadian Government provided emergency funding to the violence against women and housing and homelessness sectors in response to COVID-19, Canada lacks a national legislative and funding framework to support coordinated prevention efforts. We review the context of IPV and homelessness among women and international policy exemplars. We then propose several starting points for developing a Canadian strategic framework, including adopting inclusive definitions of IPV and homelessness as well as evaluating a broad continuum of IPV-housing options and intersectoral partnership models.

Improving the mental health of women intimate partner violence survivors: Findings from a realist review of psychosocial interventions

BACKGROUND

Intimate partner violence (IPV) is highly prevalent and is associated with a range of mental health problems. A broad range of psychosocial interventions have been developed to support the recovery of women survivors of IPV, but their mechanisms of action remain unclear.

METHODS

Realist review following a prospectively published protocol in PROSPERO (CRD42018114207) and reported using the Realist and Meta-narrative Evidence Synthesis: Evolving Standards (RAMSES) guidelines.

RESULTS

Evidence was extracted from 60 reviews and triangulated in expert consultations. Mechanisms of action were categorised as either associated with intervention design and delivery or with specific intervention components (access to resources and services; safety, control and support; increased knowledge; alterations to affective states and cognitions; improved self-management; improved family and social relations).

CONCLUSIONS

Findings suggest that psychosocial interventions to improve the mental health of women survivors of IPV have the greatest impact when they take a holistic view of the problem and provide individualised and trauma-informed support.

From ‘spectating’ to ‘spect-acting’: medical students’ lived experiences of online Forum Theatre training in consulting with domestic abuse victims

Introduction

Health care professionals, including general practitioners, have an important role in the care of those affected by domestic abuse. Therefore, it is important that healthcare professionals are adequately trained in recognising features of domestic abuse and supporting victims in disclosure. Founded by Augusto Boal, Forum Theatre is a drama methodology that can permit an experiential and immersive learning experience; lending itself well to a subject matter of oppressed individuals. In this study we aimed to gain a deep understanding of medical students’ lived experiences of training in consulting with individuals who experienced domestic abuse using an online format of forum theatre.

Methods

A multidisciplinary team developed an online forum theatre training exercise, which involved a simulated consultation between a general practitioner and domestic abuse victim. Our qualitative approach used hermeneutic phenomenology to explore the participants’ lived experiences of this training. Following the online forum theatre experience, we analysed 11 participant interviews using template analysis to structure the phenomenological interpretation.

Results

We developed five themes through our analytical process: 1) ‘Almost being there…but not quite’: the realistic experience of forum theatre; 2) ‘Taken on an emotional journey’ 3) ‘Opening and controlling a privileged space’; 4) ‘Small things matter…’: cultivating and maintaining rapport and 5) Critically reflecting on future professional self.

Discussion

This study offers fine-grained insights into medical students’ experiences of an online immersive forum theatre training exercise in consulting with individuals who have been affected by domestic abuse. Online forum theatre has the potential to provide a simulated and meaningful approach to train medical students about domestic abuse.

By providing students with a unique opportunity to step into a General Practitioner’s shoes in a domestic abuse consultation, students can practise how they manage a consultation with an impacted individual through a safe, guided, and experiential approach.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41077-022-00208-1.

Impact of the first national COVID-19 lockdown on referral of women experiencing domestic violence and abuse in England and Wales

BACKGROUND

The lockdown periods to curb COVID-19 transmission have made it harder for survivors of domestic violence and abuse (DVA) to disclose abuse and access support services. Our study describes the impact of the first COVID-19 wave and the associated national lockdown in England and Wales on the referrals from general practice to the Identification and Referral to Improve Safety (IRIS) DVA programme. We compare this to the change in referrals in the same months in the previous year, during the school holidays in the 3 years preceding the pandemic and the period just after the first COVID-19 wave. School holiday periods were chosen as a comparator, since families, including the perpetrator, are together, affecting access to services.

METHODS

We used anonymised data on daily referrals received by the IRIS DVA service in 33 areas from general practices over the period April 2017-September 2020. Interrupted-time series and non-linear regression were used to quantify the impact of the first national lockdown in March-June 2020 comparing analogous months the year before, and the impact of school holidays (01/04/2017-30/09/2020) on number of referrals, reporting Incidence Rate Ratio (IRR), 95% confidence intervals and p-values.

RESULTS

The first national lockdown in 2020 led to reduced number of referrals to DVA services (27%, 95%CI = (21,34%)) compared to the period before and after, and 19% fewer referrals compared to the same period in the year before. A reduction in the number of referrals was also evident during the school holidays with the highest reduction in referrals during the winter 2019 pre-pandemic school holiday (44%, 95%CI = (32,54%)) followed by the effect from the summer of 2020 school holidays (20%, 95%CI = (10,30%)). There was also a smaller reduction (13-15%) in referrals during the longer summer holidays 2017-2019; and some reduction (5-16%) during the shorter spring holidays 2017-2019.

CONCLUSIONS

We show that the COVID-19 lockdown in 2020 led to decline in referrals to DVA services. Our findings suggest an association between decline in referrals to DVA services for women experiencing DVA and prolonged periods of systemic closure proxied here by both the first COVID-19 national lockdown or school holidays. This highlights the need for future planning to provide adequate access and support for people experiencing DVA during future national lockdowns and during the school holidays.

Mapping the health systems response to violence against women: key learnings from five LMIC settings (2015-2020)

Background

Violence against women (VAW) is a global challenge, and the health sector is a key entry point for survivors to receive care. The World Health Organization adopted an earlier framework for health systems response to survivors. However, documentation on the programmatic rollout of health system response to violence against women is lacking in low and middle-income countries. This paper studies the programmatic roll out of the health systems response across select five low- and middle-income countries (LMIC) and identifies key learnings.

Methods

We selected five LMIC settings with recent or active programming on national-level health system response to VAW from 2015 to 2020. We synthesized publicly available data and program reports according to the components of the WHO Health Systems Framework. The countries selected are Bangladesh, Brazil, Nepal, Rwanda, and Sri Lanka.

Results

One-stop centers were found to be the dominant model of care located in hospitals in four countries. Each setting has implemented in-service training as key to addressing provider knowledge, attitudes and practice; however, significant gaps remain in addressing frequent staff turnover, provision of training at scale, and documentation of the impact of training. The health system protocols for VAW address sexual violence but do not uniformly include clinical and health policy responses for emotional or economic violence. Providing privacy to survivors within health facilities was a universal challenge.

Conclusion

Significant efforts have been made to address provider attitudes towards provision of care and to protocolize delivery of care to survivors, primarily through one-stop centers. Further improvements can be made in data collection on training impact on provider attitudes and practices, in provider identification of VAW survivors, and in prioritization of VAW within health system budgeting, staffing, and political priorities. Primary health facilities need to provide first-line support for survivors to avoid delays in response to all forms of VAW as well as for secondary prevention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01499-8.

Screening for intimate partner violence in healthcare settings: An implementation-oriented systematic review

Background

Intimate partner violence (IPV) is a population health problem affecting millions of women worldwide. Screening for IPV within healthcare settings can identify women who experience IPV and inform counseling, referrals, and interventions to improve their health outcomes. Unfortunately, many screening programs used to detect IPV have only been tested in research contexts featuring externally funded study staff and resources. This systematic review therefore investigated the utility of IPV screening administered by frontline clinical personnel.

Methods

We conducted a systematic literature review focusing on studies of IPV screening programs for women delivered by frontline healthcare staff. We based our data synthesis on two widely used implementation models (Reach, Effectiveness, Adoption, Implementation and Maintenance [RE-AIM] and Proctor's dimensions of implementation effectiveness).

Results

We extracted data from 59 qualifying studies. Based on data extraction guided by the RE-AIM framework, the median reach of the IPV screening programs was high (80%), but Emergency Department (ED) settings were found to have a much lower reach (47%). The median screen positive rate was 11%, which is comparable to the screen-positive rate found in studies using externally funded research staff. Among those screening positive, a median of 32% received a referral to follow-up services. Based on data extraction guided by Proctor's dimension of appropriateness, a lack of available referral services frustrated some efforts to implement IPV screening. Among studies reporting data on maintenance or sustainability of IPV screening programs, only half concluded that IPV screening rates held steady during the maintenance phase. Other domains of the RE-AIM and Proctor frameworks (e.g., implementation fidelity and costs) were reported less frequently.

Conclusions

IPV is a population health issue, and successfully implementing IPV screening programs may be part of the solution. Our review emphasizes the importance of ongoing provider trainings, readily available referral sources, and consistent institutional support in maintaining appropriate IPV screening programs.

Plain language abstract

Intimate partner violence (IPV) is a population health problem affecting millions of women worldwide. IPV screening and response can identify women who experience IPV and can inform interventions to improve their health outcomes. Unfortunately, many of the screening programs used to detect IPV have only been tested in research contexts featuring administration by externally funded study staff. This systematic review of IPV screening programs for women is particularly novel, as previous reviews have not focused on clinical implementation. It provides a better understanding of successful ways of implementing IPV screening and response practices with frontline clinical personnel in the context of routine care. Successfully implementing IPV screening programs may help mitigate the harms resulting from IPV against women. Findings from this review can inform future efforts to improve implementation of IPV screening programs in clinical settings to ensure that the victims of IPV have access to appropriate counseling, resources, and referrals.

PRimary care rEsponse to domestic violence and abuse in the COvid-19 panDEmic (PRECODE): protocol of a rapid mixed-methods study in the UK

Background

The implementation of lockdowns in the UK during the COVID-19 pandemic resulted in a system switch to remote primary care consulting at the same time as the incidence of domestic violence and abuse (DVA) increased. Lockdown-specific barriers to disclosure of DVA reduced the opportunity for DVA detection and referral.

The PRECODE (PRimary care rEsponse to domestic violence and abuse in the COvid-19 panDEmic) study will comprise quantitative analysis of the impact of the pandemic on referrals from IRIS (Identification and Referral to Improve Safety) trained general practices to DVA agencies in the UK and qualitative analysis of the experiences of clinicians responding to patients affected by DVA and adaptations they have made transitioning to remote DVA training and patient support.

Methods/Design

Using a rapid mixed method design, PRECODE will explore and explain the dynamics of DVA referrals and support before and during the pandemic on a national scale using qualitative data and over four years of referrals time series data.

We will undertake interrupted-time series and non-linear regression analysis, including sensitivity analyses, on time series of referrals to DVA services from routinely collected data to evaluate the impact of the pandemic and associated lockdowns on referrals to the IRIS Programme, and analyse key determinants associated with changes in referrals.

We will also conduct an interview- and observation-based qualitative study to understand the variation, relevance and feasibility of primary care responses to DVA before and during the pandemic and its aftermath.

The triangulation of quantitative and qualitative findings using rapid analysis and synthesis will enable the articulation of multiscale trends in primary care responses to DVA and complex mechanisms by which these responses have changed during the pandemic.

Discussion

Our findings will inform the implementation of remote primary care and DVA service responses as services re-configure. Understanding the adaptation of clinical and service responses to DVA during the pandemic is crucial for the development of evidence-based, effective remote support and referral beyond the pandemic.

Trial registration

PRECODE is an observational epidemiologic study, not an intervention evaluation or trial. We will not be reporting results of an intervention on human participants.

Female university students' preferences for different types of sexual relationships: implications for gender-based violence prevention programs and policies

Background

Gender-based violence among young women is a growing problem worldwide. The consequences of this victimization have been well reported in the scientific literature, among which negative health outcomes stand out. The factors influencing this problem are many; one highlighted by research is socialization into a dominant coercive discourse that associates sexual-affective attraction to males with violent attitudes and behaviors, while in turn, such discourse empties males with egalitarian behaviors from sexual attractiveness. This coercive discourse may be shaping the sexual preferences of female youth. The current paper explores young women’s preferences for different types of sexual relationships and, more particularly, for what type of sexual affective relationships they coercively preferred men with violent attitudes and behavior.

Methods

A quantitative, mixed-design vignette study was conducted with 191 college females in Spain. We focused the analysis only on responses about vignettes including narratives of men with violent attitudes and behaviors. In addition, we examined whether participants would report higher coerced preferences for violent men when asked about the coerced preferences of their female friends than when asked about their own preferences.

Results

Only 28.95% of participants responded that their female friends would prefer a young man with violent behavior for a stable relationship, meanwhile 58.42% would do it for hooking up. When reporting about themselves, the difference was greater: 28.42% would prefer a young man with violent behavior for hooking up and just 5.78% for a stable relationship.

Conclusions

The dominant coercive discourse that links attractiveness to people with violent attitudes and behaviors may be explaining the results obtained in this study. The findings can help eliminate the stereotype largely adopted by some intervention and prevention programs which assume that gender-based violence occurs mainly in stable relationships, considering that falling in love is the reason that lead women to suffer from violence. Our results can also support health professionals and others serving young women to enhance their identification of gender violence victimization, as well as our findings point to the need to include the evidence of gender violence in sporadic relationships in prevention programs and campaigns addressed to young women.

Women's experiences and expectations after disclosure of intimate partner abuse to a healthcare provider: A qualitative meta-synthesis

OBJECTIVE

To identify and synthesise the experiences and expectations of women victim/survivors of intimate partner abuse (IPA) following disclosure to a healthcare provider (HCP).

METHODS

The databases MEDLINE, Embase, CINAHL, PsychINFO, SocINDEX, ASSIA and the Cochrane Library were searched in February 2020. Included studies needed to focus on women's experiences with and expectations of HCPs after disclosure of IPA. We considered primary studies using qualitative methods for both data collection and analysis published since 2004. Studies conducted in any country, in any type of healthcare setting, were included. The quality of individual studies was assessed using an adaptation of the Critical Appraisal Skills Programme checklist for qualitative studies. The confidence in the overall evidence base was determined using Grading of Recommendations, Assessment, Development and Evaluations (GRADE)-Confidence in the Evidence from Reviews of Qualitative Research methods. Thematic synthesis was used for analysis.

RESULTS

Thirty-one papers describing 30 studies were included in the final review. These were conducted in a range of health settings, predominantly in the USA and other high-income countries. All studies were in English. Four main themes were developed through the analysis, describing women's experiences and expectations of HCPs: (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. If these key expectations were absent from care, it resulted in a range of negative emotional impacts for women.

CONCLUSIONS

Our findings strongly align with the principles of woman-centred care, indicating that women value emotional connection, practical support through action and advocacy and an approach that recognises their autonomy and is tailored to their individual needs. Drawing on the evidence, we have developed a best practice model to guide practitioners in how to deliver woman-centred care. This review has critical implications for practice, highlighting the simplicity of what HCPs can do to support women experiencing IPA, although its applicability to low-income and-middle income settings remains to be explored.

Disruption of a primary health care domestic violence and abuse service in two London boroughs: interrupted time series evaluation

Background

Domestic violence and abuse (DVA) is experienced by about 1/3 of women globally and remains a major health concern worldwide. IRIS (Identification and Referral to Improve Safety of women affected by DVA) is a complex, system-level, training and support programme, designed to improve the primary healthcare response to DVA. Following a successful trial in England, since 2011 IRIS has been implemented in eleven London boroughs. In two boroughs the service was disrupted temporarily. This study evaluates the impact of that service disruption.

Methods

We used anonymised data on daily referrals received by DVA service providers from general practices in two IRIS implementation boroughs that had service disruption for a period of time (six and three months). In line with previous work we refer to these as boroughs B and C. The primary outcome was the number of daily referrals received by the DVA service provider across each borough over 48 months (March 2013–April 2017) in borough B and 42 months (October 2013–April 2017) in borough C. The data were analysed using interrupted-time series, non-linear regression with sensitivity analyses exploring different regression models. Incidence Rate Ratio (IRR), 95% confidence intervals and p-values associated with the disruption were reported for each borough.

Results

A mixed-effects negative binomial regression was the best fit model to the data. In borough B, the disruption, lasted for about six months, reducing the referral rate significantly (p = 0.006) by about 70% (95%CI = (23,87%)). In borough C, the three-month service disruption, also significantly (p = 0.005), reduced the referral rate by about 49% (95% CI = (18,68%)).

Conclusions

Disrupting the IRIS service substantially reduced the rate of referrals to DVA service providers. Our findings are evidence in favour of continuous funding and staffing of IRIS as a system level programme.