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.
CLAHRC North Thames PhD Marissa Mes enjoyed success at the prestigious Annual Scientific Meeting (ASM) of the Asthma UK Centre for Applied Research (AUK CAR).
Marissa won best poster presentation when she showcased her work to delegates during the conference (below) – her research focus is assessing whether pharmacists are a suitable delivery channel for an intervention aimed at asthma patients to improve their adherence to preventer inhalers.
Our congratulations to Marissa on her prize.
Marissa’s fellow CLAHRC PhD Caroline Katzer, who is developing and evaluating an intervention to improve adherence to inhaled corticosteroids (ICS) in adult asthma patients also showcased her work at the conference via both a poster and an oral presentation, which generated a lot of discussion, and was among those complimented on the quality of her presentations.
Both PhDs are funded by the CLAHRC and affiliated to AUKCAR.
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.”
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
Research Assistant Moïse Roche enjoyed success at the recent prestigious Health Services Research UK conference in Nottingham.
A poster outlining Moise’s work, as part of our Improving care of people with memory problems in Black African and Caribbean groups study won the People’s Poster Prize at the event – as voted by attendees.
Congratulations to Moïse!
A project under our mental health theme focuses on improving the care of Black African and Caribbean people with memory problems, which can be an early warning sign for dementia. We know that Black African and Caribbean elders develop dementia earlier, and seek help later than their white peers.
This delay can greatly impact access to care and support, and reduce the independence of dementia patients prematurely.
We have carried out extensive engagement work within this community – running focus groups and conducting interviews to find out the perceptions and beliefs that prevent people visiting their GP when memory problems first arise.
As well as disseminating our findings we have concentrated all the learning from the project into a new leaflet “Getting help for forgetfulness“.
We co-designed this leaflet with patients and the public and it aims to encourage health-seeking behaviour among elders encountering memory problems.
It answers questions about symptoms, sets out what help is available and why you should visit your GP, and provides useful information and contacts.
We trialled the leaflet in patients without a diagnosis of dementia in several GP practices and they liked it.
We can provide printed copies to the NHS, community and voluntary groups and charities – just contact us with your needs.
Email Moïse Roche to order copies of the leaflet – firstname.lastname@example.org
School-based interventions to increase health and wellbeing
The health and wellbeing of school children is a pressing concern in England, with a growing prevalence of obesity and diabetes in childhood. It is also widely recognised that a child’s emotional health and wellbeing influences their cognitive development and learning, as well as their physical and social health and mental wellbeing in adulthood.
These increased concerns, aligned with a better recognition of the emotional and mental health needs of children, led the Greater London Authority (GLA) to develop and co-ordinate a school based health programme to improve health and wellbeing for all pupils in London.
The result was the development of the GLA’s Healthy Schools London programme (HSL) launched in April 2013 and co-ordinated by the Greater London Authority (GLA). The programme encourages schools to adopt a whole school approach to combat the specific health and wellbeing needs of their pupils by developing their policies and procedures. HSL recognises and rewards the schools’ endeavours through a system of awards: Bronze, Silver, and Gold.
A CLAHRC North Thames project recently completed a two-year evaluation of the programme. The aim of the evaluation was to assess the contribution of the programme to improving educational attainment, and health and well-being, among schoolchildren in London. It was funded jointly by the GLA and the CLAHRC, and was conducted between 2014 and 2016 by Dr Harry Rutter and Dr Andrew Barnfield from the London School of Hygiene and Tropical Medicine (LSHTM).
We conducted literature reviews, focus groups in 20 schools, interviews with 6 directors of public health and directors of children’s services, focus groups with borough leads, interviews with the GLA core team and borough leads, and two assessment visits to special schools. We also conducted an online survey across all participating schools, with a total of over 450 responses.
Was HSL effective in its aims?
- Assessed the potential for the HSL programme to influence educational achievement, promote healthy lifestyle behaviours, and reduce health inequalities in London
- Investigated the extent to which becoming a Healthy School is associated with changes in school-level policies, and activities.
- Assessed the nature and level of engagement with the HSL programme by schools, including any differential uptake by socio-economic factors, and to understand the drivers and barriers to becoming a Healthy School
- Provided recommendations to inform the ongoing development of the HSL programme
The evaluation concluded that HSL provides a valuable mechanism to encourage change at school level. Among a suite of recommendations, the evaluation suggested that:
- HSL would be strengthened by encouraging schools to work more closely together.
- A mentoring programme could help to spread best practice between schools,
- There is scope for stronger links between school sand local communities.
- The implementation of a programme to enhance health and wellbeing provision in early year’s settings could provide an additional mechanism for health improvement, and promote school preparedness among the capital’s children.
Professor Feder’s expertise includes Cardiovascular health – in particular the diagnosis and management of angina and using cardiovascular risk as a basis of treatment decisions. He was was a co-applicant on our successful bid to secure funding for the Identification and Referral to Improve Safety (IRIS): Improving the response to domestic violence and abuse project and is working with us from his base at the University of Bristol.