1. Health care responses to domestic violence: end of the beginning? Gene Feder Mental Health in the Context of Domestic Abuse Conference September 15 th 2015

2. Multi-sectoral response to violence

3. 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 violence  survivors’ expectations of doctors  evidence for effectiveness Specific health sector response

4. Specific health care response?  health impact

5. 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 violence  5x more likely to require medical attention or hospitalisation  5x more likely to report fearing for their lives  8x more likely to suffer sexual violence

6. past year prevalence of IPV (UK)

7. 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 risk  gynaecological problems

8. health impact (WHO 2005)

9. mental health consequences (Howard 2013, Golding 1999)

10. contribution to disease burden (VicHealth, 2004)

11. 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

13. Specific health care response?  health impact  survivor expectations of doctors (and other health care professionals)

14. What do survivors want from doctors? before disclosure/questioning  try to ensure continuity of care make it possible for women to disclose  ask about (current and past) abuse when issue of partner violence raised  don’t pressurise women to fully disclose immediate response to disclosure  ensure that the women feel that they have control over the situation, and address safety concerns response in later consultations  understand the chronicity of the problem and provide follow up and continued support

15. Specific health care response?  health impact  survivor expectations of doctor  evidence of effectiveness

16. a certain kind of evidence… epidemiology systematic reviews and meta-analyses RCTs + nested qualitative studies & economic analyses guidelines and policy

17. Are clinicians engaging with domestic violence? NO

18.  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

19. What should the health sector do?  build capacity of health care providers to respond  collect data on what works  advocate other sectors to respond as part of a society-wide response

20. health care professional response

21. health care providers supporting patients  knowledge and awareness about violence and abuse  ask about violence safely

22. Should we be screening in health care settings? NO

23. health care providers supporting patients  knowledge and awareness about violence and abuse  ask about violence safely  non-judgemental supportive response  facilitate access to  violence support/advocacy services  access to trauma-informed mental health services

24. system-level response

25. 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

26. IRIS Can we improve the response of clinicians to domestic violence? YES

27. But only in partnership with domestic violence advocacy organisations  advocate educator  specialist referral service  link to local domestic violence fora and coordinated community response

28. challenges  uncertainty of health care professionals barriers  health system silo  inertia in education and training development  existence of and access to support services and trauma-informed mental health services

29. 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

30. Using evidence to drive policy

31. guidelines are a stepping stone

32. New questions, new(ish) answers

33. What about male patients?

34. 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

35. Is IRIS transferable to other health care systems?

36. Can we improve outcomes for women who engage with DVA services? Uncertainty about benefit of DV advocacy/support  probably reduces risk of further DVA  mixed results from trials measuring mental health and quality of life outcomes for women receiving advocacy

37. improved mental health outcomes

38. 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

39. 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?

40. Thank you to colleagues to funders

41. gene.feder@ Bristol.ac.uk medina.johnson@nextlink housing.co.uk