Health care responses to domestic violence: end of the beginning?

Gene Feder

Mental Health in the Context of Domestic Abuse Conference

September 15th 2015

Multi-sectoral response to violence

Domestic violence is a violation of human rights and a society-wide challenge, particularly to the education and criminal justice system.

Why do we need a specific health care response?health impact of domestic violencesurvivors’ expectations of doctorsevidence for effectiveness

Specific health sector response

Specific health care response?

health impact

Why are women survivors of DV a priority for a health system response?

Compared with male survivors women are:3x more likely to be injured as a result of violence5x more likely to require medical attention or

hospitalisation5x more likely to report fearing for their lives8x more likely to suffer sexual violence

past year prevalence of IPV (UK)

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Keygeneral populationfamily planningantenatal/postnatal caregynaecology populationaccident and emergencygeneral practice

physical health consequences (Coker et al, 2009, Coker et al, 2000)

Survivors experience a range of chronic health problems including:

chronic pain increased minor infectious illnesses neurological symptoms gastrointestinal disorders raised cardiovascular riskgynaecological problems

health impact (WHO 2005)

mental health consequences (Howard 2013, Golding 1999)

contribution to disease burden (VicHealth, 2004)

risks to children’s physical and mental health

pre and post-natal risk foetal distress, pre-

eclampsia, low birth weight

all forms of maltreatment 41% overlap with direct

maltreatment

long term behavioural and mental health problems

Specific health care response?

health impactsurvivor expectations of doctors (and

other health care professionals)

What do survivors want from doctors? before disclosure/questioning

try to ensure continuity of caremake it possible for women to disclose

ask about (current and past) abusewhen issue of partner violence raised

don’t pressurise women to fully discloseimmediate response to disclosure

ensure that the women feel that they have control over the situation, and address safety concerns

response in later consultationsunderstand the chronicity of the problem and provide

follow up and continued support

Specific health care response?

health impactsurvivor expectations of doctorevidence of effectiveness

a certain kind of evidence…

epidemiology

systematic reviews and meta-analyses

RCTs + nested qualitative studies & economic analyses

guidelines and policy

Are clinicians engaging with domestic violence?

NO

system level programmes that improve: identification of victims of violence in

health care referral to violence support/advocacy

and trauma-informed psychological services

individual support/advocacy and psychological interventions can reduce further violence and improve health outcomes

(some) evidence of effectiveness

What should the health sector do?

build capacity of health care providers to respond

collect data on what worksadvocate other sectors to respond as part

of a society-wide response

health care professional response

health care providers supporting patients

knowledge and awareness about violence and abuse

ask about violence safely

Should we be screening in health care settings?

NO

health care providers supporting patients

knowledge and awareness about violence and abuse

ask about violence safelynon-judgemental supportive responsefacilitate access to

violence support/advocacy services access to trauma-informed mental health

services

system-level response

health care systems supporting providers

training about violence to all health care professionals undergraduate post-graduate continuing profesional development

system wide changes and budgetary allocation are critical

systematic data collection institutional commitment : procedures around patient

flow, documentation, privacy and confidentiality, feedback from other agencies to health care professionals, referral networks

IRIS

Can we improve the response of clinicians to domestic violence?

YES

But only in partnership with domestic violence advocacy organisations

advocate educator specialist referral service link to local domestic violence fora and

coordinated community response

challenges

uncertainty of health care professionals barriers

health system siloinertia in education and training

developmentexistence of and access to support

services and trauma-informed mental health services

action DVA needs to have a higher priority in NHS policy, budget

allocation and in training/capacity building need to integrate into training curricula, with ongoing support

and supervision sexual and reproductive health services and primary care

are crucial entry points to address violence against women strengthen mental health programmes/capacities health policy makers need to show leadership and raise

awareness of the health burden and cost

Using evidence to drive policy

guidelines are a stepping stone

New questions, new(ish) answers

What about male patients?

Can IRIS be extended to male DV survivors and outside of primary care?

Possibly

HEalth professionals Responding to MEn for Safety

Linking Abuse and Recovery

through Advocacy

Is IRIS transferable to other health care systems?

Can we improve outcomes for women who engage with DVA services?Uncertainty about benefit of DV

advocacy/supportprobably reduces risk of further DVAmixed results from trials measuring mental

health and quality of life outcomes for women receiving advocacy

improved mental health outcomes

How can health care services respond to children exposed to DVA?

IMPRoving Outcomes for children exposed to domestic ViolencE

RESPONDS

Researching Education to Strengthen Primary care ON Domestic violence & Safeguarding

unanswered questions

How should health care respond to perpetrators?

How do we extend training and pathways to achieve a safe and effective response to all survivors and their children?

What does trauma-informed care mean for the health care response to domestic violence?

Thank you

to colleagues

to funders

gene.feder@ Bristol.ac.uk

medina.johnson@nextlinkhousing.co.uk