Exploring the complex pathway of the primary health care response to intimate partner violence in New Zealand

Knowledge and practices of regional and rural general practitioners in the identification and management of intimate partner and family violence: a mixed methods study in Western Australia

BACKGROUND

General Practitioners (GPs) are well placed to identify and assist patients experiencing intimate partner violence (IPV) and family violence (FV). However, patients experiencing IPV/FV can be under-detected or inadequately assisted when GPs do not have the necessary confidence, knowledge, attitudes or skills for this. Given the high rates of IPV/FV in the Australian regional setting where this study was conducted, this investigation explored the confidence, knowledge, attitudes and practices of local GPs in identifying and managing patients who are experiencing IPV/FV.

METHODS

This mixed methods study utilised a survey tool adapted from a review of existing instruments. The adapted tool included questions on provider confidence, knowledge, attitudes and practices for quantitative analysis, as well as open-response questions that were analysed thematically. All GPs (n = 58) working within the area at the time of the study were invited to participate via emails and written letters distributed through practices and at pre-existing meetings, with 25 completing the survey (43% response rate).

RESULTS

Participants lacked knowledge around GP-facilitated disclosure of abuse, many believing the patient to be the main reason for non-disclosure. Half or fewer respondents indicated confidence in creating safety plans with patients, in making appropriate referrals and in identifying IPV/FV by history, signs and symptoms. There were mostly favourable attitudes towards asking about and assisting with IPV/FV, although only one quarter of respondents believed that individuals experiencing IPV/FV can make appropriate choices about how to handle their situation. In terms of practice, only one third agreed that they could match interventions to patient readiness to change. Other key concerns included difficulties in accessing timely support, with improved coordination of local services and systematic changes in the GP environment being the most common recommendations made by respondents.

CONCLUSIONS

This study demonstrated that the responding GPs in a regional area with high rates of IPV/FV have generally favourable attitudes towards identifying and assisting with IPV/FV but lack knowledge and confidence in the practical elements of enquiry. Surprisingly for a regional area, there was poor understanding of local support provision. The findings have the potential to meaningfully inform regional and rural primary care experiences, including desired educational opportunities and enhancing the relationship between health professionals and relevant community organisations. The results support the need for upstream changes in the general practice environment to improve the ability of regional and rural GPs to build relationships with patients over time and enhance overall health outcomes for those affected by abuse.

Complexity Science in Domestic Abuse Literature: A Systematic Scoping Review

Complexity science is an interdisciplinary paradigm that helps people understand how outcomes, such as domestic violence and abuse (DVA), arise from within complex adaptive systems. This study aims to identify how complexity science has been applied in DVA literature. A systematic scoping review was conducted, searching across academic databases and Google for articles. Articles published from 1990 to 2020, written in English, had DVA partner abuse as a focus, and used complexity science as a focus or theoretical background to the paper, were considered for inclusion. Data was extracted and narratively synthesized in an iterative manner. Twenty-one studies were included, originating predominantly from the United States and New Zealand, and published mainly after 2009. Approximately 70% of authorships were comprised of interdisciplinary teams. Most papers strongly incorporated complexity science as a methodological approach and applied methods, such as systems modeling (agent-based modeling or systems dynamics modeling), aligning with computer science or engineering disciplines. Some used complexity theory combined with qualitative techniques (interviews or discourse analysis) strongly associated with social sciences research. Methods and findings were heterogeneous and often explored interactions between parts of the system and the subsequent phenomena that emerged from these interactions. Complexity science can: (a) support a holistic understanding of DVA; (b) combine different perspectives; (c) encourage interdisciplinary teams to work collaboratively around an issue such as DVA; (d) identify leverage points to assist in targeting scarce resources; (e) help predict emergent phenomena and unexpected consequences of policy change.

'Atawhai': a primary care provider-led response to family violence in Aotearoa New Zealand

BACKGROUND

As a key determinant of ill-health, family violence is inadequately responded to within Aotearoa New Zealand health policy and practice. Without adequate system support, health professionals can often be unsure of what to do, or how to help. Developed in response to this system gap, 'Atawhai' aims to make it easier for primary care professionals to respond to family violence.

METHODS

Underpinned by indigenous Māori customs, Atawhai combines complexity theory and participatory research methodologies to be responsive to the complexity involved in family violence. We worked with 14 primary care professionals across ten whakawhitiwhiti kōrero wānanga (meetings for deliberate dialogue) to identify and develop primary care system pathways and tools for responding to family violence. This paper focuses on the development of Atawhai through wānanga and observation methods. Methods used to capture change will be reported separately.

FINDINGS

Atawhai is a relational response to family violence, focused on developing a network of trusted relationships between health and social care professionals to support safe responses to those accessing care. This study identified four key health system pathways to responsiveness and developed associated tools to support health care responsiveness to family violence. We found the quality of relationships, both among professionals and with those accessing care, coupled with critical reflection on the systems and structures that shape policy and practice are essential in generating change within primary care settings.

CONCLUSIONS

Atawhai is a unique health care response to family violence evidenced on empirical knowledge of primary care professionals. Our theoretical lens calls attention to parts of the system often obscured by current health care responses to family violence. Atawhai presents an opportunity to develop a grassroots-informed, long-term response to family violence that evolves in response to needs.

Application of complexity theory in health and social care research: a scoping review

BACKGROUND

Complexity theory has been chosen by many authors as a suitable lens through which to examine health and social care. Despite its potential value, many empirical investigations apply the theory in a tokenistic manner without engaging with its underlying concepts and underpinnings.

OBJECTIVES

The aim of this scoping review is to synthesise the literature on empirical studies that have centred on the application of complexity theory to understand health and social care provision.

METHODS

This scoping review considered primary research using complexity theory-informed approaches, published in English between 2012 and 2021. Cochrane Database of Systematic Reviews, MEDLINE, CINAHL, EMBASE, Web of Science, PSYCHINFO, the NHS Economic Evaluation Database, and the Health Economic Evaluations Database were searched. In addition, a manual search of the reference lists of relevant articles was conducted. Data extraction was conducted using Covidence software and a data extraction form was created to produce a descriptive summary of the results, addressing the objectives and research question. The review used the revised Arksey and O'Malley framework and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews (PRISMA-ScR).

RESULTS

2021 studies were initially identified with a total of 61 articles included for extraction. Complexity theory in health and social care research is poorly defined and described and was most commonly applied as a theoretical and analytical framework. The full breadth of the health and social care continuum was not represented in the identified articles, with the majority being healthcare focused.

DISCUSSION

Complexity theory is being increasingly embraced in health and care research. The heterogeneity of the literature regarding the application of complexity theory made synthesis challenging. However, this scoping review has synthesised the most recent evidence and contributes to translational systems research by providing guidance for future studies.

CONCLUSION

The study of complex health and care systems necessitates methods of interpreting dynamic prcesses which requires qualitative and longitudinal studies with abductive reasoning. The authors provide guidance on conducting complexity-informed primary research that seeks to promote rigor and transparency in the area.

REGISTRATION

The scoping review protocol was registered at Open Science Framework, and the review protocol was published at BMJ Open (https://bit.ly/3Ex1Inu).

Impact of COVID-19 on the Health Response to Family Violence in Aotearoa New Zealand: A Qualitative Study

COVID-19 pandemic planning and response has resulted in unprecedented upheaval within health systems internationally. With a concern for increasing frequency and escalation of family violence, the so called "shadow pandemic," we wondered how health system violence intervention programs were operating during this time. In Aotearoa New Zealand, the Ministry of Health Violence Intervention Program (VIP), using a systems approach, seeks to reduce and prevent the health impacts of family violence and abuse through early identification, assessment, and referral of victims presenting to designated health services. In this qualitative descriptive study, we explored how the VIP program was impacted during the first year of the COVID-19 pandemic. Forty-one VIP coordinators and managers representing 15 of the 20 New Zealand District Health Boards and the National VIP Team participated. Across 12 focus groups (8 face to face and 4 via Zoom) and 7 individual interviews (all via Zoom) participants shared their experience navigating systems to support frontline health providers' responsiveness to people impacted by family violence during the pandemic. In our reflexive thematic analysis, we generated 3 themes: Responding to the moment, valuing relationships, and reflecting on the status quo. Our findings demonstrate the dynamic environment in which participants found creative ways to adapt to the uncertainty and engage with communities to re-shape interventions and ensure continued implementation of the program. At the same time, challenges within the system prior to the pandemic were brought into view and highlighted the need for action. These included, for example, the need for improved engagement with Māori (Indigenous people of Aotearoa New Zealand) to address long-standing health inequities. Having quality essential services for those impacted by family violence that engages with local knowledge and networks and routinely copes with uncertainty will strengthen our systems to minimize risk of harm during emergencies.

Are We Asking Too Much of the Health Sector? Exploring the Readiness of Brazilian Primary Healthcare to Respond to Domestic Violence Against Women

BACKGROUND

There is growing recognition of the health sector's potential role in addressing domestic violence (DV) against women. Although Brazil has a comprehensive policy framework on violence against women (VAW), implementation has been slow and incomplete in primary healthcare (PHC), and little is known about the implementation challenges. This paper aims to assess the readiness of two PHC clinics in urban Brazil to integrate an intervention to strengthen their DV response.

METHODS

We conducted 20 semi-structured interviews with health managers and health providers; a document analysis of VAW and DV policies from São Paulo and Brazil; and 2 structured facility observations. Data were analysed using thematic analysis.

RESULTS

Findings from our readiness assessment revealed gaps in both current policy and practice needing to be addressed, particularly with regards to governance and leadership, health service organisation and health workforce. DV received less political recognition, being perceived as a lower priority compared to other health issues. Lack of clear guidance from the central and municipal levels emerged as a crucial factor that weakened DV policy implementation both by providers and managers. Furthermore, responses to DV lost visibility, as they were diluted within generic violence responses. The organizational structure of the PHC system in São Paulo, which prioritised the number of consultations and household visits as the main performance indicators, was an additional difficulty in legitimising healthcare providers' time to address DV. Individual-level challenges reported by providers included lack of time and knowledge of how to respond, as well as fears of dealing with DV.

CONCLUSION

Assessing readiness is critical because it helps to evaluate what services and infrastructure are already in place, also identifying obstacles that may hinder adaptation and integration of an intervention to strengthen the response to DV before implementation.

Family Coping Strategies to Improve the Health of Family Members Living with Schizophrenia

Introduction: Schizophrenia is a serious mental illness that affects the thinking, emotions, relationships, and decision-making. One of the positive effects of treating schizophrenia in patients is family health. The family welfare management strategies provide help for coping, care preparation, organizing meetings, and mentoring. This study focuses on family coping strategies for improving the health of members living with schizophrenia.Methods: A cross-sectional design was used by choosing 160 respondents randomly. The inclusion criteria were family members accompanying control schizophrenia patients to the Public Health Center, with a minimum age of 18. The independent variable was family coping, which consist of two sub-variables (problem-focused coping mechanism and emotion-focused coping mechanism), while the dependent variable was family health, which consists of three sub-variables (efficient, satisfaction, and happiness). The SMART PLS (2.0 Version) was used to prove the impact of the variables.Results: The results indicated that family coping had a significant impact  on the health of the family. The hypothesis was taken from the value of the T-test on the structural model analysis, which shows T- statistics (13.966) > T-critical (1.96). The impact of family coping on the health is equal to 0.682 (OR). This means that if family coping is given one-unit value, it will increase the family health by 0.682 times.Conclusion: The implementation of the family coping strategy will improve the capacity of the family to clarify health issues encountered, resolve family behaviors effectively and minimize risk factors. Furthermore, the coping mechanisms chosen by families in facing stress will have an impact on the reduction of illness symptoms in the members with schizophrenia.

Engaging with Uncertainty and Complexity: A Secondary Analysis of Primary Care Responses to Intimate Partner Violence

Complex problems generate uncertainty. The number and diversity of interactions between different health professionals, perspectives, and components of the problem makes predicting an outcome impossible. In effort to reduce the uncertainty of intimate partner violence interventions, health systems have developed standardized guidelines and protocols. This paper presents a secondary analysis of 17 New Zealand primary care professional narratives on intimate partner violence as a health issue. We conducted a complexity-informed content analysis of participant narratives to explore uncertainty in greater depth. This paper describes three ways primary care professionals interact with uncertainty: reducing uncertainty, realizing inherent uncertainty, and engaging with uncertainty. We found dynamic patterns of interaction between context and the experience of uncertainty shape possible response options. Primary care professionals that probed into uncertainty generated new understanding and opportunities to respond to intimate partner violence.

Exploring sustainable primary care responses to intimate partner violence in New Zealand: Qualitative use of complexity theory

OBJECTIVE

To explore what affects sustainable responses to intimate partner violence within New Zealand primary care settings using complexity theory.

DESIGN

Primary care professional interviews on intimate partner violence as a health issue are analysed using a complexity theory-led qualitative research methodology grounded in poststructuralism.

SETTING

Four general practices in one region of the North Island of New Zealand, two serving a general patient population and two adopting an indigenous approach.

PARTICIPANTS

Seventeen primary care professionals and management from the four recruited general practices.

RESULTS

The complex adaptive system approach the 'Triple R Pathway', calls attention to system interactions influencing intimate partner violence responsiveness across health system levels. Four exemplars demonstrate the use of the Triple R Pathway. Two key system areas challenge the emergence of primary care responsiveness: (1) Non-recognition of intimate partner violence as a key determinant of ill-health. (2) Uncertainty and doubt.

CONCLUSIONS

The relationship between intimate partner violence and ill-health is not well recognised, or understood in New Zealand, at both policy and practice levels. Inadequate recognition of socioecological determinants of intimate partner violence leads to a simple health system response which constrains primary care professional responsiveness. Constant intervention in system interactions is needed to promote the emergence of sustainable responses to intimate partner violence.