Screening and counselling in primary care for women who have experienced intimate partner violence

Lorna O’Doherty

• Criminal justice system £1.2 billion

• Health care treatment (hospital, GP, ambulance, prescriptions) £1.7 billion

• Social services £0.28 billion • Housing & refuges £0.19 billion

• Civil legal services £0.38 billion

(Walby, 2009)

• Lost economic output £1.9 billion

• Human and emotional costs £10 billion

Total cost of domestic violence per annum estimated at £16 billion

(Walby, 2009)

Health consequences are injuries, adverse pregnancy outcomes, mental health problems, poor general health (Campbell, 2002)

the problem

Impact on children (Wood & Summers, 2011)

the problem

Frequent use of health services by victims of IPVOpportunities for identifying & supporting women and children EARLY in health settingsBarriers inhibit realisation of these opportunitiesUniversal screening is not effective (O’Doherty et al. 2014)

Evidence for benefit of interventions to help women experiencing IPV in health care settings is limitedSo, what can be done for women who disclose?

the context

The problem

Society

Community

Relationship

Individual

(Heise, 1998)

Does brief counselling from family doctors trained to respond to women afraid of a (ex-)partner increase women's quality of life, safety and mental health? Cluster RCT called ‘weave’ (Hegarty, O’Doherty et al. 2013)

We enrolled family doctors from clinics (Australia), and their female patients (aged 16-50 years) who screened positive for fear of a partner in past 12 months in a health and lifestyle survey

design

Training of doctors, notification to doctors of women screening positive for fear of a partner, and invitation to women for one-to-six sessions of counselling for “relationship and emotional issues”

Control group received standard general practice care

intervention

Positive external factors

Psychosocial Readiness Model Chang (2010)

Perceived support

Awareness

Self-efficacy

Negativeexternal factors

It was hard, but not hard I don't want to do this. It was hard, wow, this is actually how I feel…It was quite therapeutic during the time, and especially at the very start where I actually forced myself to acknowledge: I am scared. I am not safe now.

The feeling of someone [weave GP] caring about me really gives me strength & hope to carry on, to believe in happiness, even though there's struggle & pain on the way.

The survey also made me more aware of my strengths which I believe gave me the confidence to not be in a relationship and know that I am okay on my own and can make my own decisions.

Primary outcomes (at 12 months)quality of life (WHO Quality of Life-BREF)safety (Safety Behaviour Checklist)mental health (SF-12)

Secondary outcomes depression and anxiety (HADS; cut-off ≥8) doctor inquiry about safety of women &

childrencomfort to discuss fear with their doctor

outcome measures

findings

baseline

Composite Abuse Scale (at baseline)

severe combined abusephysical & emo-tional abusephysical onlyemotional onlyno abuse

BL 6m 12m4045505560657075808590

BL 6m 12m4045505560657075808590

WHOQol Physical WHOQol Psychological

BL 6m 12m4045505560657075808590

BL 6m 12m40

50

60

70

80

90WHOQol Social WHOQol Environmental

no effect on primary outcomes

depressiveness caseness at 12 months was improved in the intervention group compared with the control group (odds ratio 0·3, 0·1-0·7; p=0·005), as was women’s report of doctor enquiry at 6 months about women's safety (5·1, 1·9-14·0; p=0·002) and children's safety (5·5, 1·6-19·0; p=0·008)

findings

inform further research on brief counselling for women disclosing IPV in primary care settingsdo not lend support to the use of postal screening in the identification of those patients family doctors should be trained to ask about the safety of women and children, and to provide supportive counselling for women experiencing abuse, because our findings suggest that counselling can reduce depressive symptoms

interpretation

The survey allowed me to open up and talk to my GP (weave GP) about the issues instead of the brave / confident front that I had always portrayed.

I feel by starting weave, it gave me the push I needed to get into counselling and do something about my marriage.

It helped to clarify my thoughts and feelings which was timely. That process was helpful in my eventual decision to separate.

motivation to seek help

Being frightened in a relationship is very depressing and it is hard to find people you can trust to talk about things and really open up about how you are really coping. Thanks to weave I have been able to do this.

catharsis

I had gone along with the belief I was indeed ‘mad’ crazy, gone in the head and all the other things he called me. How very liberating to find out I too was like other women. No not MAD but abused. I suffered in silence… Thank you for the chance to have a say in this study I hope we will help other women realise they are not alone, isolated or MAD.

positive reinforcement

derive further insights from weave trial – women’s interviews, long-term outcomes and

path analysis programs in primary care and other health settings for identifying and responding to male perpetrators & victimstrialling mother-child IPV prevention programs

future directions

O'Doherty LJ, Taft A, Hegarty K, Ramsay J, Davidson LL, Feder G. (2014) ‘Screening women for intimate partner violence in healthcare settings: abridged Cochrane systematic review and meta-analysis’ British Medical Journal 348, g2913

Hegarty, K.L., O'Doherty, L.J., Taft, A.J., Chondros, P., Brown, S.J., Valpied, J., Astbury, J., Taket, A., Gold, L., Feder, G.S., and Gunn, J.M. (2013) ‘Screening and counselling in the primary care setting for women who have experienced intimate partner violence (weave): a cluster randomised controlled trial’ The Lancet 382(9888), 249-258

Valpied, J., Cini, A., O'Doherty, L.J., Taket, A., and Hegarty, K.L. (In Press) “Sometimes cathartic. Sometimes quite raw”: Benefit and harm in an intimate partner violence trial Aggression and Violent Behavior

references