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Lancet paper: Indentifying domestic violence in general practice

13 October 2011

Lancet study shows how general practice can substantially improve care for women experiencing domestic violence

One in four women in the UK have experienced physical or sexual abuse from their husband or a partner. A programme of training and support for GPs, practice nurses and GP receptionists can substantially increase the identification of women experiencing domestic violence and their referral to specialist advocacy services, according to new research from the University of Bristol, published in The Lancet.

A collaboration with Barts and the London School of Medicine and Dentistry, the University of the West of England, Next Link and the nia project, the study demonstrates the benefits of such training and support interventions in primary care settings.  Currently, most doctors have no training in how to deal with patients experiencing domestic violence, fail to identify such patients, and are uncertain about how best to help them.

Professor Gene Feder of Bristol’s School of Social and Community Medicine and colleagues studied 48 general practices in Bristol and Hackney, London.  Of these, 24 received a training and support programme called IRIS (Identification and Referral to Improve Safety) and 24 did not.

After a year, the practices that had received IRIS training recorded 641 disclosures of domestic violence while the practices without training recorded 236.  The practices with training recorded referral of 223 patients to domestic violence advocacy services and the control practices recorded 12.

Professor Feder said: “The substantial difference in referrals is strong evidence that the IRIS programme improves the response of doctors and nurses to women experiencing domestic violence and enables access to domestic violence advocacy that can reduce re-victimisation and improve quality of life and possibly mental health outcomes for these patients.”

The IRIS programme comprised two 2-hour training sessions for doctors incorporating case studies and practice in asking about violence and responding appropriately.  The sessions were delivered by an advocate educator based in one of the two collaborating specialist agencies (Next Link in Bristol and the nia project in Hackney), and either a clinical psychologist specialising in domestic violence or an academic family doctor.

Administrative staff received one-hour training sessions which focused on issues of confidentiality and safety for patients who are abused and introduced IRIS posters and leaflets signposting domestic violence agencies.

The domestic violence advocate educator then provided ongoing support to clinicians and reception staff in the practices to consolidate this initial training.

Other components of the intervention included a template in the electronic medical record linked to diagnoses such as depression, anxiety, irritable bowel syndrome, pelvic pain, and assault, a simple referral pathway to a named advocate in a specialist domestic violence agency, and cards and posters about domestic violence visible in the practices.

Professor Feder said: “A unique and probably essential feature of the IRIS model was the hybrid role of the advocate educator who both trained practices in the identification of, and response to, women experiencing domestic violence, and who became the named advocate to whom clinicians could refer. The IRIS model was rooted in a close partnership with third-sector specialist agencies, linking primary care into an inter-sectoral response to violence against women. At a time when the funding to these agencies is being cut, our study supports the case for increasing their funding, with the NHS commissioning advocate educators to provide a crucial link between general practice and the specialist advocacy support that survivors of domestic violence need. ”

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