Acting on family violence: how the health system can step up

The health system has a vital role in ensuring doctors and nurses provide an appropriate, first-line response to victims of family violence. But it’s lagging behind. Today, I’ll be telling the Victorian Government’s Royal Commission into Family Violence how the health system can step up to the challenge.

At least 80% of women experiencing abuse seek help from health services, usually general practice. It’s estimated a general practitioner sees up to five abused women weekly who present with symptoms of violence in the home. Some patients suffer depression, anxiety and long-term headaches. For others, the stress of abuse can lead to premature labour or even miscarriage. Doctors treat the symptoms and often don’t ask about the cause; women sometimes don’t tell.

There are currently excellent guidelines some health professionals follow, but others don’t. This isn’t enough. Health professionals need compulsory training to ensure better health and safety outcomes for women and children experiencing domestic violence. Only an organisational shift can make this happen. Practitioners need a supportive environment and changes in health system protocols and polices.

It should be noted that many of the studies in this area are based on women, as they are the main victims of severe physical and sexual abuse. But the same principles apply to male victims.

Removing barriers

Women face many barriers to discussing family violence with professionals. They include shame, worries about being judged or disbelieved, and confidentiality concerns. Many doctors have had minimal to no training in dealing with the effects of partner violence. Some don’t have the time to respond adequately if a patient discloses their experience.

Policymakers and researchers have suggested screening (asking all women attending a clinic or hospital a standard set of questions) to overcome these barriers and help doctors and nurses identify patients experiencing family violence.

Screening may sound like a good idea but many practitioners are reluctant to use it. They might feel overwhelmed by the emotional task of responding to disclosures. Further, health professionals sometimes have their own experience of family violence which, if recent, might hinder their willingness to bring it up with patients.

Although screening helps identify some women experiencing domestic violence, the numbers are still lower than expected. Screening also doesn’t increase referrals to specialist services or improve women’s health outcomes. A US study released last week showed no long-term health benefits to women who were screened and provided with a partner violence resource list.

The World Health Organisation doesn’t recommend screening in health settings unless the woman is pregnant. A global review of more than a dozen studies has backed up this advice. It concludes the small amount of existing evidence shows identification increases but has little benefit to women.

Training professionals

The lack of evidence for screening doesn’t mean doctors and nurses shouldn’t use prompting questions to investigate whether family violence is present when women and children show recognised symptoms. If patients feel ready to disclose abuse, health professionals should show empathy and follow up with safety questions. Women should be listened to, believed, asked about their needs, have their risk and safety assessed and be offered ongoing support.

Some women are ready for referrals at the point of disclosure. For the many who aren’t, studies have suggested family doctors be trained to provide supportive counselling. This has been shown to reduce depressive symptoms in women experiencing abuse.

Advocacy is also beneficial. This is where appropriately trained health-care providers or specialist family violence services give women information and psychological support to access community resources. Survivors can be linked with legal, police, housing and financial services. Advocacy and support intervention trials for women who have sought help from shelters report reductions in violence and improvements in mental health.

For training to be effective, it must be provided as part of university courses and throughout a practitioner’s career. Health professionals usually respond best when they are trained by a peer. Effective training also involves role-playing asking and responding with actors, reflections on personal attitudes towards violence against women, hearing survivor stories and reviewing patients’ files.

While doctors’ and nurses’ ability to respond appropriately when they suspect family violence is vital, it can only work if the broader health system is supportive of women-centred care.

Health system response

A whole-of-system response involves an appropriate, sensitive environment for traumatised people, strong management support for the importance of the work, and practitioner support and mentoring. In the United States, some of these system changes have led to a dramatic increase in numbers identified.

Governments should create policies to facilitate referral pathways for health professionals, both internally and externally, with community services. Policies should also ensure data collection and information-sharing between agencies. Health settings can create supportive environments with leaflets and posters promoting awareness about family violence consultations and referrals.

The Commonwealth government could add Medicare item numbers for general practitioners, psychiatrists, psychologists and social workers (with family violence training) – similar to the current mental health care plans – to undertake safety planning. These would allow for longer, half-an-hour sessions.

State governments can:

• Allocate funding for regional health services to have family violence coordinators and for every hospital to have a clinical professional implement organisational change.
• Allocate finances to overstretched family violence services for women, children and men.
• Fund trauma-informed counselling for mothers and children, as recommended by the World Health Organization. This would help fill Australia’s chasm of referral options, particularly for women and children who have left the relationship.

Finally, we must ensure the health recommendations heard at the Royal Commission today lead to practical outcomes. If health professionals continue to only treat symptoms of family violence, the cycle of women’s physical and mental deterioration and damage to children will continue.

Kelsey Hegarty received funding from NHMRC for the weave trial. She has been a Temporary Clinical Advisor for the WHO and an author on the Cochrane Clinical Reviews.