Elsevier

The Lancet

Volume 378, Issue 9805, 19–25 November 2011, Pages 1788-1795
The Lancet

Articles
Identification and Referral to Improve Safety (IRIS) of women experiencing domestic violence with a primary care training and support programme: a cluster randomised controlled trial

https://doi.org/10.1016/S0140-6736(11)61179-3Get rights and content

Summary

Background

Most clinicians have no training about domestic violence, fail to identify patients experiencing abuse, and are uncertain about management after disclosure. We tested the effectiveness of a programme of training and support in primary health-care practices to increase identification of women experiencing domestic violence and their referral to specialist advocacy services.

Methods

In this cluster randomised controlled trial, we selected general practices in two urban primary care trusts, Hackney (London) and Bristol, UK. Practices in which investigators from this trial were employed or those who did not use electronic records were excluded. Practices were stratified by proportion of female doctors, postgraduate training status, number of patients registered, and percentage of practice population on low incomes. Within every primary care trust area, we randomised practices with a computer-minimisation programme with a random component to intervention or control groups. The intervention programme included practice-based training sessions, a prompt within the medical record to ask about abuse, and a referral pathway to a named domestic violence advocate, who also delivered the training and further consultancy. The primary outcome was recorded referral of patients to domestic violence advocacy services. The prespecified secondary outcome was recorded identification of domestic violence in the electronic medical records of the general practice. Poisson regression analyses accounting for clustering were done for all practices receiving the intervention. Practice staff and research associates were not masked and patients were not aware they were part of a study. This study is registered at Current Controlled Trials, ISRCTN74012786.

Findings

We randomised 51 (61%) of 84 eligible general practices in Hackney and Bristol. Of these, 24 received a training and support programme, 24 did not receive the programme, and three dropped out before the trial started. 1 year after the second training session, the 24 intervention practices recorded 223 referrals of patients to advocacy and the 24 control practices recorded 12 referrals (adjusted intervention rate ratio 22·1 [95% CI 11·5–42·4]). Intervention practices recorded 641 disclosures of domestic violence and control practices recorded 236 (adjusted intervention rate ratio 3·1 [95% CI 2·2–4·3). No adverse events were recorded.

Interpretation

A training and support programme targeted at primary care clinicians and administrative staff improved referral to specialist domestic violence agencies and recorded identification of women experiencing domestic violence. Our findings reduce the uncertainty about the benefit of training and support interventions in primary care settings for domestic violence and show that screening of women patients for domestic violence is not a necessary condition for improved identification and referral to advocacy services.

Funding

Health Foundation.

Introduction

Domestic violence is threatening behaviour, violence, or abuse (psychological, physical, sexual, financial, or emotional) between adults who are relatives, partners, or ex-partners. It is a severe breach of human rights with profound health consequences, particularly for women who, compared with men, experience more sexual violence, more severe physical violence, and more coercive control from their partners.1, 2, 3 The life-time population prevalence of physical and sexual violence varies internationally from 15% to 71%4 and is consistently higher in women seeking health care,5 including primary care.6

Domestic violence damages health.7 Survivors have chronic health problems including: gynaecological disorders,8 chronic pain,9 neurological symptoms,9 gastrointestinal disorders,9 and self-reported heart disease.10 The most prevalent effect is on mental health, including persistent post-traumatic stress disorder, depression, anxiety, suicidal ideation, and substance misuse.11, 12 Health-care services, particularly primary care, can be a survivor's first or only point of contact with professionals13 and abused women identify doctors as the professionals from whom they would most like to seek support.14 The magnitude of the health consequences of domestic violence contrasts with its virtual invisibility within primary health care; in one questionnaire study15 based in general practice only 15% of women with a history of domestic violence had any reference to violence in their medical record. If women disclose domestic violence to a clinician, there is evidence of an inappropriate, poor quality response.16 Doctors and nurses are largely unaware of appropriate interventions and have seldom received effective or, in the UK,16 any training about domestic violence.

Findings from a systematic review17 of 15 controlled studies showed that training and organisational change within health-care systems can increase the identification of women experiencing domestic violence by health-care professionals,17 but revealed uncertainty about the effect of these interventions on referral to specialist services for domestic violence or other outcome measures beyond identification. In an update to that review up until December 2009, we found four more randomised controlled trials of health-care system interventions of training and screening in health-care settings, with equivocal evidence of improved referrals to specialist domestic violence services18, 19 and mixed evidence of benefit to women screening positive for intimate partner violence.20, 21 Overall, the effectiveness of domestic violence training models for primary care clinicians, particularly outside north America, remains uncertain.

Our aim in this trial was to test the effectiveness of a programme of training and support to improve the response of primary health-care practices to domestic violence. The programme focused on the identification of women experiencing domestic violence, an appropriate initial response by clinicians, and referral to a specialist advocacy service, if that was what the woman wanted. Domestic violence advocacy includes provision of legal, housing, financial and safety planning advice, and facilitation of access to community resources, such as refuges or shelters, emergency housing, and psychological support.22 Advocacy for women with recent experience of domestic violence reduces risk of further physical violence,23 improves quality of life,24 and can improve mental health outcomes.25

Section snippets

Study design and participants

The protocol for this study is available online.

General practices in two urban primary care trusts (administrative bodies contracting all NHS general practice services in geographically specified areas), one in the south west of England (Bristol) and the other in east London (Hackney), UK, were eligible for participation. Exclusion criteria were investigators of this study working in the practices or the practices not using electronic records. The Identification and Referral to Improve Safety

Results

The intervention was delivered between Sept 1, 2007, and Sept 30, 2008. 51 (62%) of 82 eligible practices agreed to participate (figure 1). These practices had a similar proportion of female doctors, but were larger, had a higher proportion of patients on low incomes, and had a higher proportion of postgraduate teaching than did practices that declined participation (table 1). Of the 51 randomised practices, three dropped out before we obtained baseline data. Table 2 shows the baseline

Discussion

The IRIS training and support intervention had a substantial effect on recorded referrals to specialist domestic violence agencies and on recorded identification of women experiencing domestic violence, albeit from a low baseline. The primary outcome, a record of referral to a domestic violence agency within the electronic general practice medical record overestimated actual referral, because clinicians might have recorded a referral when they gave the patient an IRIS card or telephone number.

References (32)

  • BJ Morse

    Beyond the Conflict Tactics Scale: assessing gender differences in partner violence

    Violence Vict

    (1995)
  • P Tjaden et al.

    Extent, nature, and consequences of intimate partner violence: findings from the national violence against women survey

    (2000)
  • G Feder et al.

    How far does screening women for domestic (partner) violence in different health-care settings meet criteria for a screening programme? Systematic reviews of nine UK National Screening Committee criteria

    Health Technol Assess

    (2009)
  • K Hegarty

    What is intimate partner abuse and how common is it?

  • AE Bonomi et al.

    Medical and psychosocial diagnoses in women with a history of intimate partner violence

    Arch Intern Med

    (2009)
  • JM Golding

    Intimate partner violence as a risk factor for mental disorders: a meta-analysis

    J Fam Violence

    (1999)
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