Outcomes of domestic violence screening at an acute London trust: are there missed opportunities for intervention?

Patient-reported outcome measures in adult HIV care: A rapid scoping review of targeted outcomes and instruments used

OBJECTIVE

There is international interest in the integration of patient-reported outcome measures (PROMs) into routine HIV care, but little work has synthesized the content of published initiatives. We conducted a rapid scoping review primarily to identify their selected patient-reported outcomes and respective instruments.

METHODS

Four databases were searched on 4 May 2022 (Medline, Embase, CINAHL and PsychINFO) for relevant English language documents published from 2005 onwards. Dual review of at least 20% of records, full texts and data extraction was performed. Outcomes and instruments were classified with an adapted 14-domain taxonomy. Instruments with evidence of validation were described.

RESULTS

Of 13 062 records generated for review, we retained a final sample of 94 documents, referring to 60 distinct initiatives led mostly in the USA (n = 29; 48% of initiatives), Europe (n = 16; 27%) and Africa (n = 9; 15%). The measured patient-reported outcome domains were: mental health (n = 42; 70%), substance use (n = 23; 38%), self-management (n = 16; 27%), symptoms (n = 12; 20%), sexual/reproductive health (n = 12; 20%), physical health (n = 9; 15%), treatment (n= 8; 13%), cognition (n = 7; 12%), quality of life (n = 7; 12%), violence/abuse (n = 6; 10%), stigma (n = 6; 10%), socioeconomic issues (n = 5; 8%), social support (n = 3; 5%) and body/facial appearance (n = 1; 2%). Initiatives measured 2.6 outcome domains, on average (range = 1-11). In total, 62 distinct validated PROMs were identified, with 53 initiatives (88%) employing at least one (M = 2.2). Overwhelmingly, the most used instrument was any version of the Patient Health Questionnaire to measure symptoms of depression, employed by over a third (26; 43%) of initiatives.

CONCLUSION

Published PROM initiatives in HIV care have spanned 19 countries and disproportionately target mental health and substance use.

Systematic screening of gender violence and domestic violence among HIV-positive patients: the VIHOLETA study

We conducted a multicentre observational study in people living with HIV (PLHIV) on antiretroviral therapy in Alicante (Spain) from 2019 to 2020 aiming to analyse the prevalence of abuse and assess treatment adherence according to this variable. We used the Abuse Assessment Screen tool, the simplified medication adherence questionnaire and the medication possession ratio to assess outcomes.. Of the 161 included PLHIV, 53 (32.9%) had suffered abuse (27 emotional abuse, 6 physical abuse, 3 sexual abuse, 13 emotional and physical abuse, 4 unknown type). Seven (4.3%) had suffered abuse in the last year (5 emotional, 2 physical). Abuse had lasted a median of 48 months (interquartile range 12-81). HIV status was considered as a cause of violence by 9.4% of victims. In the multivariable analysis, only abuse was independently associated with non-adherence [adjusted odds ratio (aOR) 3.92; 95% confidence interval (CI) 1.80-8.84; p = 0.0007]. Abuse (aOR 6.14; 95% CI 1.63-27.70; p = 0.001) and previous incarceration (aOR 15.08 95% CI 2.71-104.71; p = 0.003) were associated with detectable viral load. In conclusion, the prevalence of abuse is high in PLHIV, hampering adherence and virological success. Abuse screening tools should be incorporated into routine HIV care.

A hospital-based independent domestic violence advisor service: demand and response during the Covid-19 pandemic

Background and aim

Recent UK policy has focussed on improving support for victims of domestic violence and abuse (DVA), in healthcare settings. DVA victims attending hospital are often at highest risk of harm, yet DVA support in hospitals has been inadequate. A targeted service supporting high risk DVA victims, was implemented at a hospital Trust in North West England. The service was provided by Independent Domestic Violence Advisors (IDVAs). This paper assesses the activity in the hospital-based IDVA service during the COVID-19 pandemicand addresses the research questions: What was the demand for the service? How did the service respond? What facilitated this response?

Methods

A mixed-methods study was undertaken. Quantitative data on referrals to the service were examined using simple descriptive statistics and compared to other DVA services. Semi-structured interviews were undertaken with IDVAs and other hospital staff involved with the service and the data subjected to thematic analysis.

Results

The quantitative analysis showed that referrals dropped at the start of lockdown, then increased and continued to rise; the qualitative findings reiterated this pattern. Referrals came from a range of departments across the Trust, with the majority from A&E. Pre-pandemic, the population supported by the service included higher proportions of males and people aged 40 and over than at other IDVA services; this continued during the pandemic. The qualitative findings indicated a flexible response during the pandemic, enabled by strong working relationships and by using workarounds.

Conclusions

The hospital-based IDVAs provided an efficient, flexible serviceduring the COVID-19 pandemic. Referrals increased during the first lockdown and subsequent relaxing of restrictions. Locating the IDVAs within a team working across the organisation, and building good working relationships facilitated an effective disclosure and referral route, which endured through social restrictions. The IDVAs supported high-risk victims who may otherwise not have been identified in traditional community-based DVA settings during the pandemic. Hospital-based IDVA services can broaden access by supporting vulnerable, at risk populations whose needs may not be identified at other services.

Identifying domestic violence and sexual assault presentations at a regional Australian hospital emergency department: Comparative analysis of domestic violence and sexual assault cases

Objective:

To map the main characteristics of and differences between domestic violence and sexual assault cases presenting to a hospital emergency department in Australia.

Methods:

This retrospective observational cross-sectional study presents a snapshot of domestic violence and sexual assault cases presenting to the emergency department of a regional tertiary Australian hospital between 1 January 2018 and 31 December 2018. Data were extracted from the health district electronic information system for all eligible females. All data were checked for completeness and discrepancies by researchers before analysis.

Results:

42/105 (40%) sexual assault cases and 27/56 (48%) domestic violence cases reported mental health issues. More than half of the sexual assault and domestic violence cases had recurrent presentations to emergency department (51%; 54/105% and 52%; 29/56, respectively); most injuries were classed as severe. 92/105; 88% of sexual assault and 41/56; 73% of domestic violence victims were referred to related services.

Conclusion:

Clinical health staff, particularly those working in emergency department, can play crucial roles in identifying cases of domestic violence and sexual assault. Domestic violence training for clinicians and routine domestic violence screening in hospital emergency department is recommended to enhance early intervention.

[Domestic Violence and Intimate Partner Violence - a Challenge within the Health Care Sector - Result of a Survey Among Physicians]

Domestic violence evidently endangers health. Since physicians are seen as primary contact persons by victims of violence it is necessary to understand their perception of their role. 1346 of all physicians and dentists registered in 2015 with the Saxony Board of Physicians filled in a questionnaire on contact with victims, knowledge on support structures and willingness to take part on specific medical education. Frequency of contact was estimated to be low, while readiness to approach patients in case of suspicion was high. There was uncertainty about where to refer, as well as a limited level of awareness of existing support structures. Most indicated a high request in further education. In conclusion, motivation and readiness contrast with uncertainty and lack of awareness. Education focusing on key players and major network interfaces should endorse physicians in their significant role within the care and prevention system of violence.

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.

Boundary-Work and the Distribution of Care for Survivors of Domestic Violence and Abuse in Primary Care Settings: Perspectives From U.K. Clinicians

Health care encounters are opportunities for primary care practitioners to identify women experiencing domestic violence and abuse (DVA). Increasing DVA support in primary care is a global policy priority but discussion about DVA during consultations remains rare. This article explores how primary care teams in the United Kingdom negotiate the boundaries of their responsibilities for providing DVA support. In-depth interviews were undertaken with 13 general practitioners (GPs) in two urban areas of the United Kingdom. Interviews were analyzed thematically. Analysis focused on the boundary practices participants undertook to establish their professional remit regarding abuse. GPs maintained permeable boundaries with specialist DVA support services. This enabled ongoing negotiation of the role played by clinicians in identifying DVA. This permeability was achieved by limiting the boundaries of the GP role in the care of patients with DVA to identification, with the work of providing support distributed to local specialist DVA agencies.

Application of the Consolidated Framework for Implementation Research to Facilitate Violence Screening in HIV Care Settings: a Review of the Literature

PURPOSE OF REVIEW

This review summarizes the literature on violence screening practices within HIV care settings globally as well as identified salient multi-level barriers and facilitators for adopting and implementing violence screening within HIV care. We utilized the Consolidated Framework for Implementation Research (CFIR) to systematically identify multi-level factors related to violence screening within HIV services.

RECENT FINDINGS

Across the 15 articles included, several highly salient CFIR constructs emerged as particularly relevant for violence screening adoption and implementation within HIV including inner setting factors, outer setting factors, as well as select constructs specific to characteristics of the violence screening process, the individuals charged with screening, and violence screening execution. This review underscores the importance of considering CFIR constructs to bolster successful violence screening implementation in HIV care settings. We describe several potential implementation strategies to overcome the most salient barriers identified across this limited body of summarized research.

"From taboo to routine": a qualitative evaluation of a hospital-based advocacy intervention for domestic violence and abuse

Background

Health services are often the first point of professional contact for people who have experienced domestic violence and abuse. We report on the evaluation of a multi-site, hospital-based advocacy intervention for survivors of domestic violence and abuse. Independent Domestic Violence Advisors (IDVAs), who provide survivors with support around safety, criminal justice, and health and wellbeing, were located in five hospitals in England between 2012 and 2015 in emergency departments and maternity services. We present views about IDVAs’ approaches to tackling domestic violence and abuse, how the IDVA service worked in practice, and factors that hindered and facilitated engagement with survivors.

Methods

We adopted a convenience sampling approach and invited participation from all who offered to take part within the study timeframe. Sixty-four healthcare professionals, IDVAs, IDVA service managers, and commissioners at all sites were interviewed. Interviews were analysed using a thematic approach: familiarising ourselves with the data through repeated readings and noting initial ideas; generating initial codes through double coding notable features of the data across the dataset; collating codes into potential themes; and reviewing themes to ensure they captured the essence of the data.

Results

Two key themes emerged. The first was Hospital-based IDVAs fulfil several crucial roles. This theme highlighted that healthcare professionals thought the hospital-based IDVA service was valuable because it enhanced their skills, knowledge, and confidence in asking about domestic violence and abuse. It enabled them to immediately refer and provide support to patients who might have otherwise been lost along a referral pathway. It also reached survivors who might otherwise have remained hidden. The second theme was Success hinges on a range of structural factors. This theme illustrated the importance of ongoing domestic violence and abuse training for staff, the IDVA having private and dedicated space, and the service being embedded in hospital infrastructure (e.g. featuring it in hospital-wide policies and enabling IDVAs access to medical records).

Conclusion

Hospital-based IDVAs offer a unique and valued way to respond to domestic violence and abuse in a healthcare setting. Further work must now be done to explore how to implement the service sustainably.

Cry for health: a quantitative evaluation of a hospital-based advocacy intervention for domestic violence and abuse

Background

Domestic violence and abuse (DVA) damages the health of survivors and increases use of healthcare services. We report findings from a multi-site evaluation of hospital-based advocacy services, designed to support survivors attending emergency departments and maternity services.

Methods

Independent Domestic Violence Advisors (IDVA) were co-located in five UK hospitals. Case-level data were collected at T1 (initial referral) and T2 (case closure) from survivors accessing hospital (T1 N = 692; T2 N = 476) and community IDVA services (T1 N = 3544; T2 N = 2780), used as a comparator. Measures included indicators of sociodemographic characteristics, experience of abuse, health service use, health and safety outcomes. Multivariate analyses tested for differences in changes in abuse, health and factors influencing safety outcomes. Health service use data in the 6 months pre-and post- intervention were compared to generate potential cost savings by hospital IDVA services.

Results

Hospital IDVAs worked with survivors less visible to community IDVA services and facilitated intervention at an earlier point. Hospital IDVAs received higher referrals from health services and enabled access to a greater number of health resources. Hospital survivors were more likely to report greater reductions in and cessation of abuse. No differences were observed in health outcomes for hospital survivors. The odds of safety increased two-fold if hospital survivors received over five contacts with an IDVA or accessed six or more resources / programmes over a longer period of time. Six months preceding IDVA intervention, hospital survivors cost on average £2463 each in use of health services; community survivors cost £533 each. The cost savings observed among hospital survivors amounted to a total of £2050 per patient per year. This offset the average cost of providing hospital IDVA services.

Conclusions

Hospital IDVAs can identify survivors not visible to other services and promote safety through intensive support and access to resources. The co-location of IDVAs within the hospital encouraged referrals to other health services and wider community agencies. Further research is required to establish the cost-effectiveness of hospital IDVA services, however our findings suggest these services could be an efficient use of health service resources.

Improving the healthcare response to domestic violence and abuse in primary care: protocol for a mixed method evaluation of the implementation of a complex intervention

Background

Domestic violence and abuse remains a major health concern. It is unknown whether the improved healthcare response to domestic violence and abuse demonstrated in a cluster randomised controlled trial of IRIS (Identification and Referral to Improve Safety), a complex intervention, including general practice based training, support and referral programme, can be achieved outside a trial setting. Aim: To evaluate the impact over four years of a system wide implementation of IRIS, sequentially into multiple areas, outside the setting of a trial.

Methods

An interrupted time series analysis of referrals received by domestic violence and abuse workers from 201 general practices, in five northeast London boroughs; alongside a mixed methods process evaluation and qualitative analysis. Segmented regression interrupted time series analysis to estimate impact of the IRIS intervention over a 53-month period. A secondary analysis compares the segmented regression analysis in each of the four implementation boroughs, with a fifth comparator borough.

Discussion

This is the first interrupted time series analysis of an intervention to improve the health care response to domestic violence. The findings will characterise the impact of IRIS implementation outside a trial setting and its suitability for national implementation in the United Kingdom.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5865-z) contains supplementary material, which is available to authorized users.

Improving the healthcare response to domestic violence and abuse in sexual health clinics: feasibility study of a training, support and referral intervention

Objectives

Sexual health and gynaecological problems are the most consistent and largest physical health differences between abused and non-abused female populations. Sexual health services are well placed to identify and support patients experiencing domestic violence and abuse (DVA). Most sexual health professionals have had minimal DVA training despite English National Institute for Health and Care Excellence recommendations. We sought to determine the feasibility of an evidence-based complex DVA training intervention in female sexual health walk-in services (IRIS ADViSE: Identification and Referral to Improve Safety whilst Assessing Domestic Violence in Sexual Health Environments).

Methods

An adaptive mixed method pilot study in the female walk-in service of two sexual health clinics. Following implementation and evaluation at site 1, the intervention was refined before implementation at site 2. The intervention comprised electronic prompts, multidisciplinary training sessions, clinic materials and simple referral pathways to IRIS ADViSE advocate-educators (AEs). The pilot lasted 7 weeks at site 1 and 12 weeks at site 2. Feasibility outcomes were to assign a supportive DVA clinical lead, an IRIS ADViSE AE employed by a local DVA service provider, adapt electronic records, develop local referral pathways, assess whether enquiry, identification and referral rates were measurable.

Results

Both sites achieved all feasibility outcomes: appointing a supportive DVA clinical lead and IRIS ADViSE AE, establishing links with a local DVA provider, adapting electronic records, developing local referral pathways and rates of enquiry, identification and referral were found to be measurable. Site 1: 10% enquiry rate (n=267), 4% identification rate (n=16) and eight AE referrals. Site 2: 61% enquiry rate (n=1090), a 7% identification rate (n=79) and eight AE referrals.

Conclusions

IRIS ADViSE can be successfully developed and implemented in sexual health clinics. It fulfils the unmet need for DVA training. Longer-term evaluation is recommended.

Abused women's experiences of a primary care identification and referral intervention: a case study analysis

AIMS

The aim of this study was to report the findings of a qualitative case study that investigated abused women's experiences of an identification and referral intervention and to discuss the implications for nurses, specifically those working in primary and community care.

BACKGROUND

Domestic violence and abuse is a significant public health issue globally but it is a hidden problem that is under-reported. In the UK, Identification and Referral to Improve Safety is a primary care-based intervention that has been found to increase referral rates of abused women to support and safety services. This paper reports on the findings of an evaluation study of two sites in England.

DESIGN

Qualitative study with a case study design.

METHODS

In line with case study design, the entire evaluation study employed multiple data collection methods. We report on the qualitative interviews with women referred through the programme. The aim was to elicit their experiences of the three aspects of the intervention: identification; referral; safety. Data collection took place March 2016.

FINDINGS

Ten women took part. Eight had exited the abusive relationship but two remained with the partner who had perpetrated the abuse. Women were overwhelmingly positive about the programme and irrespective of whether they had remained or exited the relationship all reported perceptions of increased safety and improved health.

CONCLUSION

Nurses have an important role to play in identifying domestic violence and abuse and in referral and safety planning. As part of a portfolio of domestic violence and abuse interventions, those that empower women to take control of their safety (such as Identification and Referral to Improve Safety) are important.