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The Health Service contribution to tackling Domestic Violence Prof. Ann Taket Head, School of Health & Social Development, Deakin University, Australia.

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Presentation on theme: "The Health Service contribution to tackling Domestic Violence Prof. Ann Taket Head, School of Health & Social Development, Deakin University, Australia."— Presentation transcript:

1 The Health Service contribution to tackling Domestic Violence Prof. Ann Taket Head, School of Health & Social Development, Deakin University, Australia Stopping Domestic Violence: What Works? 28 th to 30 th May 2008, Waterford Institute of Technology

2 Outline Scale and nature of intimate partner abuse Health consequences Routine and selective enquiry Women’s experience Health professional views Models for enquiry Training, support and other needs Stopping Domestic Violence: What Works? 28 th to 30 th May 2008, Waterford Institute of Technology

3 Nature of intimate partner abuse IPA defined as: “the exercise of control by one adult person, usually a man, over another adult, usually a woman, within the context of an intimate relationship [current or past]. Such abuse may manifest itself in a variety of ways including physical violence, emotional or psychological abuse, sexual violence and abuse, financial control and abuse and the imposition of social isolation or movement deprivation,” (from Greater London Domestic Violence Strategy, 2001) exercise of coercive control Stopping Domestic Violence: What Works? 28 th to 30 th May 2008, Waterford Institute of Technology

4 Scale of the problem – frequency and reach In most countries, IPA will affect at least one in four ever-partnered women at some time during their adult life found in all socio-demographic groups in all societies Stopping Domestic Violence: What Works? 28 th to 30 th May 2008, Waterford Institute of Technology

5 WHO Multi-country Study 1 15 sites in 10 countries (Bangladesh, Brazil, Ethiopia, Japan, Peru, Namibia, Samoa, Serbia and Montenegro, Thailand and the United Republic of Tanzania), where possible urban and rural setting in each 24,000 women in total range of lifetime prevalence of physical or sexual violence, or both, between 15% and 71% 1.WHO multi-country study on women’s health and domestic violence against women: summary report of initial results on prevalence, health outcomes and women’s responses. Geneva, World Health Organization, Stopping Domestic Violence: What Works? 28 th to 30 th May 2008, Waterford Institute of Technology

6 Scale of the problem - impact major societal costs, annually –Australia 1, IPA $8.1 billion, $408 per person –UK 2, cost to the NHS for physical injuries alone, £1.2 billion, £20 per person IPA is the leading cause of death and disability among women of age in Victoria, Australia 3 1. Access Economics (2005) The cost of domestic violence to the Australian economy: Part 1. Canberra. 2. Walby S (2004) The Cost of Domestic Violence. Women and Equality Unit, Department of Trade and Industry, last downloaded 21/3/ VicHealth 2004, The Health Costs of Violence: Measuring the Burden of Disease Caused by Intimate Partner Violence, A summary of findings, Victorian Health Promotion Foundation, Melbourne. Stopping Domestic Violence: What Works? 28 th to 30 th May 2008, Waterford Institute of Technology

7 Health consequences - physical Injuries from assault Chronic health problems such as irritable bowel syndrome, backache, and headaches 1 Increased unintended pregnancies, terminations 2, and low birthweight babies 3 Higher rates of sexually transmitted infections, including HIV 4 1. Campbell JC. Health consequences of intimate partner violence. Lancet 2002;359: Gazmararian JA, et al. Violence and reproductive health: current knowledge and future research directions. Maternal Child Health J 2000;4(2): Murphy CC, et al Abuse: a risk factor for low birth weight? A systematic review and meta- analysis. Can Med Assoc J 2001;164: Garcia-Moreno C, Watts C. Violence against women: its importance for HIV and AIDS. AIDS 2000;14(suppl): S Stopping Domestic Violence: What Works? 28 th to 30 th May 2008, Waterford Institute of Technology

8 Health consequences - mental Compared to women who have not experienced partner violence, those who have are: –4 times as likely to have depression –4 times as likely to have PTSD –6 times as likely to abuse alcohol –4 times as likely display suicidality Golding J. (1999) Intimate partner violence as a risk factor for mental disorders: a meta-analysis. Journal of Family Violence 14(2): Stopping Domestic Violence: What Works? 28 th to 30 th May 2008, Waterford Institute of Technology

9 Routine and selective enquiry Routine enquiry: asking all [possible] women in setting direct questions about experiences, if any, of domestic abuse, regardless of whether there are signs of abuse or whether abuse is suspected Selective enquiry: asking women directly about their experiences, if any, of domestic abuse where there are concerns or suspicions, including in the presence of particular signs/symptoms Stopping Domestic Violence: What Works? 28 th to 30 th May 2008, Waterford Institute of Technology

10 ‘Nicki’ – a case study In her early 30s 2 children Relatively long history (years) of abuse Initially kept isolated at home Once children were at school realised “something was wrong” Stopping Domestic Violence: What Works? 28 th to 30 th May 2008, Waterford Institute of Technology

11 ‘Nicki’: coordinated service response Visits GP about injuries GP tells her about specialist outreach worker who does sessions at the practice Saw outreach worker the next day Enters refuge with children a few days later Relatively quickly offered suitable property by the local authority Leaves refuge for new home after 3 months Stopping Domestic Violence: What Works? 28 th to 30 th May 2008, Waterford Institute of Technology

12 ‘Mary’: a case study In her early fifties No children Emotional abuse for over 20 years Intensified over time Physical abuse started 3 years ago Enters refuge after contacting Samaritans Stopping Domestic Violence: What Works? 28 th to 30 th May 2008, Waterford Institute of Technology

13 ‘Mary’ - missed opportunities Abortion counselling Visits GP with psychological distress Psychiatric inpatient Police Visits GP for help for husband Stopping Domestic Violence: What Works? 28 th to 30 th May 2008, Waterford Institute of Technology

14 From women’s own words – on needing direct questions “Told him [her GP] I’d fell. … He didn’t quiz me about it. He didn’t say anything more about it. I just said I fell and the look he gave was, ‘well, I don’t think you have, but…’. I remember sitting there and thinking ‘quiz me, quiz me, ask me’, and he never did. … because he didn’t, I didn’t tell.” [‘Kerry’, Salford] “I don’t know what to say to them actually. What they might think, this pathetic person, why do I put up with all this?” [‘Mary’, Birmingham] Stopping Domestic Violence: What Works? 28 th to 30 th May 2008, Waterford Institute of Technology

15 Asking – professional views “If you ask people – don’t pussyfoot around … I remember when I first plucked up the courage to ask on an antenatal visit. I had never seen this woman before. She wasn’t in this particular relationship but she had previously. She gave me the reasons to carry on because she said, “You must ask everybody. Because I just wanted somebody to come out and ask me.” She lived in a nice house, partner, everything hunky dory, and she were really depressed, and her health visitor kept saying, “I can’t see why you’re depressed.” She just wanted someone to ask her. That gave me the reason to carry on asking. I think we need to keep on asking, because they might not tell you the first time you ask them. I don’t think I would. So I tell them not to be surprised if I ask them again.” [Health visitor, Wakefield] Stopping Domestic Violence: What Works? 28 th to 30 th May 2008, Waterford Institute of Technology

16 From women’s own words – on needing direct questions “I just wish somebody would of come right out and asked me. I always hope they’ll do that. Then it wouldn’t really be like me tellin’ on nobody. I’m scared to tell first.” Quoted in Drake 1982 Stopping Domestic Violence: What Works? 28 th to 30 th May 2008, Waterford Institute of Technology

17 Asking – professional views “It’s like taking care of someone’s bad knee and not taking any notice of the fact that they weigh 25 stone and don’t do any exercise. If you ignore it, you can’t manage your patient effectively. I felt [IPA] was a huge undiagnosed problem. I felt uncomfortable about what to do, so it [the training] was a good opportunity to go and find out. I’ve got this lady who is a victim of abuse, but it is emotional and financial; it used to be physical, but not anymore. … And because we both know, we can talk about it; we don’t pretend that I can make her better. She has been offered help, and she’s refused, she copes the way she can. … I don’t beat myself up that I can’t get her better. At least I know I have been able to offer the help. … we can keep talking about it until she decides to deal with it in a more formal way. That is going to take time.” [GP, Wakefield] Stopping Domestic Violence: What Works? 28 th to 30 th May 2008, Waterford Institute of Technology

18 Asking – professional views “I think (the training) gave me insight into why people don’t leave, because I think your initial reaction when somebody tells you is “Leave” and if they don’t leave then it is their fault. But things aren’t that simple. It’s taught me a little how to support people if they decide to stay in that situation because you can’t just wash your hands of them. You need to provide on-going support and advise them how to stay safe while in that situation.” [Health visitor, Wakefield ] Stopping Domestic Violence: What Works? 28 th to 30 th May 2008, Waterford Institute of Technology

19 Asking direct questions in health care settings Asking is acceptable to majority of women Asking uncovers significant numbers of previously hidden cases of IPA Repeated enquiry at a number of consultations increases likelihood of disclosure Many women will not disclose abuse without being directly asked Trained staff find asking acceptable and helpful Stopping Domestic Violence: What Works? 28 th to 30 th May 2008, Waterford Institute of Technology

20 Advantages of routine enquiry contributes to changing social attitudes to IPA less likely to make women experiencing abuse feel stigmatised less likely to compromise safety of women experiencing abuse health professionals report that their perceptions about which women were free from abuse were often incorrect Stopping Domestic Violence: What Works? 28 th to 30 th May 2008, Waterford Institute of Technology

21 Health professionals’ views “It was quite a shock to me that people don’t talk to me about it unless they’re asked. Some patients where I was rather sniggering to myself and knowing the answer would be ‘no’, I heard, ‘Yes, I’ve dealt with it, I was abused….’ It has made me routinely ask about it.” [GP, Wakefield] Stopping Domestic Violence: What Works? 28 th to 30 th May 2008, Waterford Institute of Technology

22 Training for enquiry At least one day Include: –nature and extent of health problems –how to ask questions –how to respond appropriately to disclosure –safety planning AND safe documentation Provide information on local availability of specialised services Recognition of trainees’ own needs regarding any personal experience of abuse Stopping Domestic Violence: What Works? 28 th to 30 th May 2008, Waterford Institute of Technology

23 Models of routine enquiry ----Needs to be implemented flexibly---- A: GP asks one woman each surgery session B: Practice runs a well-woman clinic, women are invited once every 3 years C: Practice nurse before/after GP consultation D: During routine home visit following childbirth E: During antenatal sessions F: At A&E/Minor injuries unit/Walk in centre Stopping Domestic Violence: What Works? 28 th to 30 th May 2008, Waterford Institute of Technology

24 Conclusions scope for tackling IPA through health service is enormous many missed opportunities: –changing attitudes about IPA –giving information about specialised services –using routine and selective enquiry importance of training importance of expert specialised non-statutory agencies like Women’s Aid Stopping Domestic Violence: What Works? 28 th to 30 th May 2008, Waterford Institute of Technology

25 In women’s own words…… “And sometimes you still get down, but I know when I'm down without a shadow of a doubt, I'm going to come back. I'm happier now. ….. In one of my things I wrote at college - … I [wrote] 'I was somebody's wife, I was somebody's mother and then I was somebody's possession and, now, I'm me' [emphasised]. That you should put down because that I feel is relevant.” [‘Jean’, Wakefield] Stopping Domestic Violence: What Works? 28 th to 30 th May 2008, Waterford Institute of Technology


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