New CLAHRC research has highlighted a lack of guidance for health and social professionals who encounter children exposed to domestic violence.

Around one in five children in the UK have been exposed to domestic violence or abuse between their parents or caregivers. Children can be directly impacted – leading to emotional and behavioural problems and risks of physical injury and death when children are caught up in the violence between adults.  Even when not directly involved, children’s exposure continues through witnessing and being aware of the violence – and through its health, social and financial consequences. Health and social care workers are often the first professionals to have contact with a child experiencing these situations.

In a collaboration with CLAHRC East of England and international colleagues from the McMaster and Western Universities in Canada we examined the evidence on child, parent and professional views on acceptable approaches to identifying and responding to children exposed to domestic violence.

The resulting research paper, published in BMJ Open, highlighted conflicting views of children and mothers on the one hand and professionals on the other when it came an ideal response. Children and mothers wanted professionals to talk to children directly and engage them in safety planning. Professionals preferred to engage with children via the parent and they often did not perceive children exposed to domestic violence as patients or clients in their own right.

Guidelines for health professionals who encounter women who have experienced domestic violence provide various questions and prompts they can use in discussions, and a set of principles to follow. There are no equivalent recommendations on how to identify and respond to children exposed to domestic violence and limited evidence on which to base future guidance. Our analysis also revealed that professionals were not happy with the existing safety guidelines for children and mothers exposed to domestic violence and wanted changes.

The research was funded by the Public Health Agency of Canada through funding to the VEGA (Violence, Evidence, Guidance and Action) project. The VEGA Project is part of the Canadian Government’s Public Health Response to Family Violence. This research will inform the development of public health guidance, protocols, curricula and tools for health and social service providers. The research was supported by the NIHR CLAHRC North Thames and NIHR CLAHRC East of England.

Resources supporting this new research include a blog in The Conversation by lead researcher Dr Natalia Lewis, and we have worked with CLAHRC East of England on a joint BITE – a summary of the research with key learning for busy professionals interested in this work.

Read the paper

Natalia V. Lewis, Gene S. Feder, Emma Howarth, Eszter Szilassy, Jill R. McTavish, Harriet L. MacMillan, Nadine Wathen.

Identification and initial response to children’s exposure to intimate partner violence: a qualitative synthesis of the perspectives of children, mothers and professionals.

BMJ Open 2018. Published in BMJ Open. April 2018. Doi:. http://bmjopen.bmj.com/content/8/4/e019761

Read a BITE sized summary

How should health and social care professionals identify and respond to children experiencing domestic violence?

Natalia Lewis, University of Bristol

Around one in five children in the UK have been exposed to domestic violence or abuse between their parents or caregivers. When adults are involved in an abusive relationship, their children bear the consequences.

The effects of domestic violence on a child can range from emotional and behavioural problems to physical injury and death when children are caught up in the violence between adults.

Even when not directly involved, children’s exposure continues through witnessing and being aware of the violence – and through its health, social and financial consequences.

Health and social care workers are often the first professionals to have contact with a child experiencing these situations. This could be when the abused parent seeks help, or when children undergo health checks. It can happen during assessments for emotional or behavioural problems, or when social services, a child’s school or the police become involved.

The World Health Organisation (WHO) recommends that health professionals who see women with clinical signs of domestic violence should ask them about safety in their relationship and at home. They advise that responses to disclosure should follow what is known as the “LIVES” principles: Listen, Inquire about needs and concerns, Validate, Enhance safety, and provide Support.

But there are no equivalent recommendations for children, and there is no agreed approach regarding how best to identify and respond to children who are exposed to domestic violence. So far, there has also been only limited evidence on which to base future guidance.

Now researchers at universities in the UK (Bristol, Queen Mary and Cambridge) and Canada (McMaster and Western) have combined existing evidence on the best ways to identify and respond to children experiencing domestic violence. This synthesis, the first of its kind, integrates findings from 11 studies with 42 children, 220 parents, and 251 health care and social services professionals.

We found that study participants’ opinions were strikingly consistent, and matched the LIVES principles. Children, parents (mostly mothers) and professionals agreed that identification of the problem should happen in the context of a good patient-professional relationship, and in a safe and supportive environment.

Health care professionals should enquire about the child’s safety when they see clinical signs of domestic violence and abuse in children. The ideal initial response should include emotional support, discussion about domestic violence and advice on local specialist services.

We also discovered that a professional’s ability to identify and respond to children’s exposure to domestic violence was heavily influenced by constraints within the health and social service system. Lack of time, funding cuts and poor inter-agency collaboration all have an impact. Professionals needed more training and resources to be able to respond to these children and their families in an appropriate and safe way.

However, there was a difference of opinion when it came to engaging directly with children and managing their safety.

A direct approach?

Children and mothers wanted professionals to talk to children directly and engage them in safety planning. Professionals, on the other hand, preferred to engage with children via the parent – and did not perceive children exposed to domestic violence as patients or clients in their own right. Also, professionals were not happy with existing safety guidelines and practices for children and mothers exposed to domestic violence. These elements are certainly subjects for future research and training.

Given the scale of the problem, and the long-term emotional, behavioural and physical impacts on children, we hope that the results of this study can form the basis of new, internationally agreed guidelines.

Our research findings have already been used to inform point-of-care responses to adults and children in Canada’s VEGA (Violence, Evidence, Guidance, Action) Project. That program is already developing the “Recognising and Responding Safely to Family Violence” Handbook for health and social care professionals.

And we hope our evidence will inspire development of professional training and resources elsewhere – so that front line practitioners feel better equipped to appropriately and safely respond directly to the needs of children. Too many children’s lives and futures could depend upon it.

Natalia Lewis, Research Fellow in Primary Care, University of Bristol

This article was originally published on The Conversation. Read the original article.

The findings of the joint CLAHRC West and CLAHRC North Thames study of the IRIS ADViSE pilot, which aimed to improve sexual health professionals’ response to women who have experienced domestic violence, are now available as a CLAHRC BITE.

Women who have experienced domestic violence and abuse (DVA) are three times more likely to have gynaecological and sexual health problems such as sexually transmitted infections, urinary tract infections and unintended pregnancy. Forty-seven per cent of women attending sexual health services will have experienced DVA at some point in their lives.

These services can be the first point of contact for women who have experienced DVA, so sexual health practitioners can have a key role in supporting women to access advocacy services. But most sexual health professionals haven’t had much training in identifying and responding to DVA, despite National Institute for Health and Care Excellence (NICE) recommendations.

The IRIS (Identification and Referral to Improve Safety) programme is an evidence-based training intervention for general practice staff to identify, respond and appropriately refer women who are affected by DVA. It is being implemented in general practice nationwide. IRIS ADViSE (Assessing for Domestic Violence in Sexual Health Environments) adapts the IRIS approach for sexual health staff.

This project looked at the feasibility and acceptability of the IRIS ADViSE pilot in sexual health clinics in Bristol and East London. The pilot aimed to encourage sexual health staff to ask patients whether they were experiencing DVA, and to make referrals to specialist services.

IRIS ADViSE included all staff training, patient information materials, an enquiry prompt in the electronic patient record and a simple referral pathway to DVA advocacy services.

In the east London clinic over seven weeks:

• 267 out of 2,568 women attending were asked about DVA
• 16 of those (6 per cent) said that they were affected by abuse
• Overall, eight of the women affected by abuse (50 per cent) were referred to specialist services

In the Bristol clinic over 12 weeks:

• 1,090 out of 1,775 women attending were asked about DVA
• 79 of those (7 per cent) said they were affected by abuse
• Overall, eight of the women affected by abuse (10 per cent), were referred to specialist services

During the three months before the pilot started, there were no referrals to DVA specialist services at either site.

We also interviewed sexual health clinic staff and DVA advocate workers in Bristol.

All the people we interviewed felt that asking about and referring women on to DVA services was appropriate and valuable in a sexual health setting. They responded favourably to the training and felt more confident about asking about DVA and managing disclosures.

Staff said that patients’ welcomed being asked about it, even if they’ve not ever been involved in an incident of domestic abuse themselves, that they appreciate that people are asking that question.

The staff reported that some disclosures were considered relatively simple and easy to handle, where patients can be easily referred to the partner DVA organisation or given information.

However, cases with an immediate risk of harm to the patient or their children were more complex in terms of managing the patient’s wishes and navigating existing safeguarding procedures. This added to staff’s already limited time and busy workloads.

Dr Jeremy Horwood (pictured below), lead researcher from the Centre for Academic Primary Care at University of Bristol and NIHR CLAHRC West, said:

“Sexual health staff are definitely supportive of asking their patients about domestic violence and abuse. But it’s crucial that they have support to do so, as these patients must be dealt with sensitively and referred on appropriately.

“At the policy and commissioning level, stronger recognition of the issues around domestic violence and abuse referrals, and resources to support them, are needed. Commissioners and local NHS trusts need to engage and commit to support domestic violence and abuse training, and to support programmes such as IRIS ADViSE.”

The study shows that it is feasible and acceptable to develop and implement the IRIS ADViSE training and referral package for sexual health clinics. At the policy and commissioning level, stronger recognition of the issues around DVA referrals, and more resources to support them, are needed. Commissioners and local NHS trusts need to engage and commit to financially support IRIS ADViSE to maximise its potential.

This study is part of CLAHRC North Thames’ wider collaboration with our colleagues at CLAHRC West.  Researchers and staff work across London and Bristol sites each bringing their own expertise and experience to produce high-quality research.  Our teams regularly meet to coordinate their work, and develop bids for funding for future work.

For this IRIS ADViSE project CLAHRC North Thames led on the work at the initial pilot site, focusing on the quantitative analysis; whereas CLAHRC West led on the qualitative analysis.

Links and downloads

BMJ talk medicine
Domestic violence affects a quarter of UK women: the role of sexual health practitioners
Listen to a podcast hosted by Editor in Chief of Sexually Transmitted Infections Jackie Cassell who is joined by Neha Pathak (Wellcome Trust Clinical PhD Fellow, Institute for Epidemiology & Healthcare, University College London) and Gene Feder (University of Bristol, Centre for Academic Primary Care) to discuss the various forms of the abuse and how healthcare practitioners can intervene.

Read our CLAHRC BITE summarising the research
Improving the response to domestic violence in sexual health clinics

Read the full research papers –

Sohal AH, Pathak N, Blake S, Apea, V. Berry, J. Bailey, J. Griffiths, C. Feder, G. (2018)
Improving the healthcare response to domestic violence and abuse in sexual health clinics: feasibility study of a training, support and referral intervention
SexuallyTransmitted Infections doi: 10.1136/sextrans-2016-052866

Horwood J, Morden A, Bailey JE, Pathak, N and Feder, G. (2018)
Assessing for domestic violence in sexual health environments: a qualitative study
Sexually Transmitted Infections. doi: 10.1136/sextrans-2017-053322

Pathak N, Sohal AH, Feder G.(2017)
How to enquire and respond to domestic violence and abuse in sexual health clinics.
Sexually Transmitted Infections. 2017 May;93(3):175-178. doi: 10.1136/sextrans-2015-052408. Epub 2016 Jul 25.

Training clinicians to proactively ask patients about domestic violence and abuse (DVA) is feasible for sexual health clinics to implement and could increase referrals to specialist services, according to a joint CLAHRC North Thames/CLAHRC West study led by researchers at Queen Mary University of London (QMUL) and the University of Bristol involving over 4,300 women.

The risk of gynaecological and sexual health problems (including sexually transmitted infections, painful sex, vaginal bleeding and recurrent urinary tract infections) is three-fold higher in women who have suffered DVA. Meanwhile, 47 per cent of women attending sexual health services will have experienced DVA at some point in their lives.

Sexual health services can be the first point of contact for women who have experienced DVA, and were listed by the National Institute for Health and Care Excellence (NICE) as a setting in which all patients should be asked about DVA. However, most sexual health professionals have had minimal training in identifying and responding to DVA.

The study looked at the feasibility of sexual health clinics adopting a programme called IRIS (Identification and Referral to Improve Safety) – a DVA training and referral programme endorsed by NICE, the Royal College of GPs and Department of Health, originally aimed at encouraging GPs to ask patients whether they are experiencing DVA and to make referrals to specialist domestic violence services.

The team tested the intervention in two female walk-in sexual health services; an east London clinic serving an inner-city multi-ethnic population, and a Bristol clinic serving an urban population.

In the east London clinic over seven weeks, 267 out of 2,568 women attending were asked about DVA, with 16 of those (6 per cent) saying that they were affected by abuse. Overall, eight of the women affected by abuse (50 per cent) were referred to specialist services.

In the Bristol clinic over twelve weeks, 1,090 out of 1,775 women attending were asked about DVA, with 79 of those (7 per cent) saying they were affected by abuse. Overall, eight of the women affected by abuse (10 per cent), were referred to the specialist services.

Lead CLAHRC North Thames researcher Dr Alex Sohal (pictured left) said: “Women attend sexual health clinics for care of their sexual health but little thought is given to whether the relationship with the person that a woman has sex with directly harms her health. Without training, system level changes and senior managerial support, clinicians end up ignoring DVA in consultations or have an arbitrary approach that fails many women affected by DVA. Not only is this a feasible intervention for a sexual health clinic setting, but we also found that clinical leads and busy local DVA service providers were incredibly supportive, with many people understanding the importance of making this work.”

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Read the full paper:
Improving the healthcare response to domestic violence and abuse in sexual health clinics: feasibility study of a training, support and referral intervention
Sohal AH, Pathak N, Blake S, et al. Sex Transm Infect Published Online First: doi:10.1136/ sextrans-2016-052866