Making sexual and reproductive healthcare environments safe and supportive for disclosure of sexual violence: interview findings from patients and healthcare professionals using a realist approach.

OBJECTIVES: Most people who have experienced sexual violence (SV) will disclose the event(s) to someone. Key recipients of disclosure are those working in healthcare. Telling someone in healthcare about experiences of SV can be an important step in accessing necessary medical care and being signposted to other services. While recognising healthcare settings are a key place for people to seek support, evidence is lacking about how best to create a safe environment for disclosure to take place, how services can make changes to better facilitate this experience and what changes matter most. DESIGN: This study used a realist approach to identify mechanisms that facilitate safe and supported disclosure. Data were generated through three focus groups with Sexual and Reproductive Health Services healthcare professionals in the UK, and one-to-one interviews with survivors of SV who attended healthcare settings (n=18). RESULTS: The analysis found that service users needed to feel empowered and recognised as appropriate candidates for care in the material used to promote sexual healthcare services after SV. This promotional material needs to address rape myths, stereotypes and silence surrounding SV, to ensure that all individuals and especially those from diverse groups are empowered to access care. Three fundamental mechanisms for safe and supported disclosure were identified: being listened to, being validated and having choice. Trauma-informed care was identified as being essential for implementing these mechanisms. Healthcare professionals who were confident and competent regarding enquiry about SV and response to disclosures of SV were key. CONCLUSIONS: The development of services that are conducive to the disclosure of SV is needed to provide better support for those who have experienced SV and are ready to seek support. Use of appropriate promotional material, specific staff training and a trauma-informed approach are key elements to improve services.

Workplace interventions to prevent suicide: A scoping review.

OBJECTIVES: To map organisational interventions for workplace suicide prevention, identifying the effects, mechanisms, moderators, implementation and economic costs, and how interventions are evaluated. BACKGROUND: Suicide is a devastating event that can have a profound and lasting impact on the individuals and families affected, with the highest rates found among adults of work age. Employers have a legal and ethical responsibility to provide a safe working environment for their employees, which includes addressing the issue of suicide and promoting mental health and well-being. METHODS: A realist perspective was taken, to identify within organisational suicide prevention interventions, what works, for whom and in what circumstances. Published and unpublished studies in six databases were searched. To extract and map data on the interventions the Effect, Mechanism, Moderator, Implementation, Economic (EMMIE) framework was used. Mechanisms were deductively analysed against Bronfenbrenner's socio-ecological model. RESULTS: From 3187 records screened, 46 papers describing 36 interventions within the military, healthcare, the construction industry, emergency services, office workers, veterinary surgeons, the energy sector and higher education. Most mechanisms were aimed at the individual's immediate environment, with the most common being education or training on recognising signs of stress, suicidality or mental illness in oneself. Studies examined the effectiveness of interventions in terms of suicide rates, suicidality or symptoms of mental illness, and changes in perceptions, attitudes or beliefs, with most reporting positive results. Few studies reported economic costs but those that did suggested that the interventions are cost-effective. CONCLUSIONS: It seems likely that organisational suicide prevention programmes can have a positive impact on attitudes and beliefs towards suicide as well reducing the risk of suicide. Education, to support individuals to recognise the signs and symptoms of stress, mental ill health and suicidality in both themselves and others, is likely to be an effective starting point for successful interventions.

Six aspects of female genital mutilation education (SAFE) model: findings from a qualitative study.

OBJECTIVES: Recent figures show that over 200 million women and girls, globally, live with the consequences of female genital mutilation (FGM). Complex debilitating physical, psychological and social problems result from the practice. Health education interventions have proven to be essential in both preventing the practice and informing support of survivors. In this study, we aimed to explore factors that affect the effectiveness of health education interventions. DESIGN: A generic qualitative approach was applied using semistructured individual and focus group interviews with women and men from communities with a history of FGM in Birmingham, UK. Framework analysis was used to group recurring themes from the data. Intersectionality was used as a theoretical lens to synthesise findings. PARTICIPANTS: Twenty-one individuals (18 women and 3 men) participated in semistructured individual and focus group interviews about their views and experiences of health and well-being intervention programmes related to FGM. RESULTS: Six themes emerged from the data and were developed into a model of issues relating to FGM education. These six themes are (1) active communication, (2) attitudes and beliefs, (3) knowledge about FGM, (4) social structures, (5) programme approach and (6) the better future. A combined discussion of all these issues was compressed into three groupings: social structures, culture and media. CONCLUSION: The results of this study depict aspects associated with FGM education that should be considered by future interventions aiming to prevent the practice and inform support services for survivors in a holistic way.

Working the Edge: The Emotional Experiences of Commissioning and Funding Arrangements for Service Leaders in the Sexual Violence Voluntary Sector.

The specialist voluntary sector plays a crucial role in supporting survivors of sexual violence. However, in England, short-term funding underpins the sector's financial stability. This article examines sector leaders' ways of coping, resisting and being affected by funding practices. Using the concept of edgework, we show how funding and commissioning dynamics push individuals to the edge of service sustainability, job satisfaction, and emotional well-being. We examine how these edges are "worked," for example, by circumventing and remolding the edge. We offer an original way to theorize participants, make visible the emotional toll of service precarity and offer suggestions for support.

Service evaluation of an independent domestic violence advocate post in a children's hospital.

Domestic violence and abuse (DVA) has detrimental effects on the health and well-being of children and young people exposed to it, whether they witness or experience it. The introduction of independent domestic violence advocates in UK hospitals has enhanced the safety of victims of DVA. In 2020-2021 an independent domestic violence advocate post was piloted at a children's hospital for one year, the advocate's role being to train hospital staff and support women who had experienced DVA. A service evaluation showed that the training and support provided by the independent domestic violence advocate had benefits for women, children and staff. It also confirmed that the commissioning of services for children exposed to DVA is often underfunded and overshadowed by the provision of support to adults.

Where do those experiencing sexual violence seek help and is routine enquiry acceptable within a sexual healthcare setting? Findings from a population-based survey.

OBJECTIVES: Most sexual violence (SV) remains undisclosed to healthcare professionals. The aims of this study were to identify where support would be sought after SV and whether routine enquiry about SV was acceptable in a sexual healthcare setting. DESIGN: An online population-based survey collected data on a history of SV and preferences on support after SV, in addition to sociodemographic data. Respondents' views on being routinely asked about SV were sought. SETTING AND PARTICIPANTS: This online survey was based in England, UK. There were 2007 respondents. RESULTS: The police were the most frequent first choice for support after experiencing SV (n=520; 25.9%); however, this was less common in individuals in younger age groups (p<0.001) and in those with a history of SV (17.2% vs 29.9%, p<0.001). For the 27.1% (532 of 1960) of respondents who reported a history of SV, the first choice of place for support was Rape Crisis or similar third-sector organisation. The majority of respondents supported routine enquiry about SV during Sexual and Reproductive Health Service (SRHS) consultations (84.4%), although acceptability was significantly lower in older age groups. CONCLUSIONS AND STUDY IMPLICATIONS: A greater awareness of the influence of sociodemographic factors, including ethnicity, age, gender, disability and a history of SV, when planning and delivering services for those who have experienced SV is needed. A history of SV is common in the general population, and a 'one-size-fits-all' approach to encourage disclosure and access to support is unlikely to be optimal. Routine enquiry about SV is highly acceptable in an SRHS setting and likely to improve disclosure when appropriately implemented.

Healthcare interventions for sex workers: protocol for a scoping review.

INTRODUCTION: Sex workers, who provide sexual or erotic acts in exchange for payment, often experience multiple disadvantages, including mental ill health and substance misuse. Mainstream healthcare services are generally not configured to facilitate engagement with sex workers and therefore, services are needed that are accessible to this population. The aim of this scoping review is to understand the evidence base for approaches, services and interventions that are aimed at addressing sex workers' health needs. METHODS AND ANALYSIS: Nine databases, CINAHL, Embase, EThOS, Google Scholar, Health Management Information Consortium, MEDLINE, ProQuest Dissertations and Theses, PsycINFO and Web of Science (Core Collection), will be searched, with results limited to English language publications and those published from 2003 onwards. De-duplication, study selection and data extraction will be conducted using Covidence software. Included studies will describe or evaluate approaches, services or interventions that address the health needs of sex workers who offer services that involve physical contact with a client. ETHICS AND DISSEMINATION: No ethical review is needed. The final report will be shared with Birmingham City Council as part of ongoing work and will be disseminated by peer-reviewed publication. STUDY REGISTRATION: Open Science Framework (doi: 10.17605/OSF.IO/N7WSX).

Exposure to Domestic Abuse and the Subsequent Development of Atopic Disease in Women.

BACKGROUND: Exposure to domestic violence and abuse (DVA) is a global public health issue associated with substantial morbidity and mortality. There are few high-quality studies that assess the impact of DVA exposure on the development of atopic disease. OBJECTIVE: To examine the association between exposure to DVA and the subsequent development of atopy. METHODS: In this population-based, retrospective, open cohort study, we identified women with no history of atopic disease between January 1, 1995 and September 30, 2019 from IQVIA Medical Research Data, an anonymized UK primary care dataset. We used clinical codes to identify exposed patients (those with a code identifying exposure to DVA; n = 13,852) and unexposed patients (n = 49,036), who were matched by age and deprivation quintile. Cox proportional hazards regression was used to calculate hazard ratios (HRs) (with 95% CIs) of developing atopic disease: asthma, atopic eczema, or allergic rhinoconjunctivitis. RESULTS: During the study period, 967 exposed women (incidence rate, 20.10/1,000 person-years) developed atopic disease, compared with 2,607 unexposed women (incidence rate, 13.24/1,000 person-years). This translated to an adjusted HR of 1.52 (95% CI, 1.41-1.64) accounting for key confounders; asthma (adjusted HR = 1.69; 95% CI, 1.44-1.99), atopic eczema (adjusted HR = 1.40; 95% CI, 1.26-1.56), and allergic rhinoconjunctivitis (adjusted HR = 1.63; 95% CI, 1.45-1.84). CONCLUSIONS: Domestic violence and abuse is a significant global public health issue. These results demonstrate a significant associated risk for developing atopic disease. Public health approaches to the prevention and detection of DVA are necessary to reduce the associated ill health burden.

Impact evaluation and economic benefit analysis of a domestic violence and abuse UK police intervention.

This study evaluated the impact and economic benefit of Cautioning and Relationship Abuse (CARA), an intervention which aims to reduce re-offending of first-time low-level domestic violence and abuse perpetrators. The analysis was based on two samples drawn from separate UK police force areas. CARA's impact was assessed using a matched sample of similar offenders from a time when CARA was not available. The matching was based on a host of offender and victim characteristics and machine learning methods were employed. The results show that the CARA intervention has a significant impact on the amount of recidivism but no significant reduction in the severity of the crimes. The benefit-cost ratio in both police force areas is greater than one and estimated to be 2.75 and 11.1, respectively, across the two police force areas. Thus, for each pound (£) invested in CARA, there is an economic benefit of 2.75-11.1 pounds, annually.

Providing a Supportive Environment for Disclosure of Sexual Violence and Abuse in a Sexual and Reproductive Healthcare Setting: A Realist Review.

Background: Sexual and reproductive healthcare services (SRHS) are an environment where medical care relevant to sexual violence and abuse (SV) is available. However, barriers to disclosure need to be overcome to allow timely access to this care. There is limited research identifying and explaining how interventions remove barriers and create a safe and supportive environment for disclosure. The purpose of this review was to develop and refine theories that explain how, for whom and in what context SRHS facilitate disclosure. Methods: Following published realist standards we undertook a realist review. After focussing the review question and identifying key contextual barriers, articles pertaining to these were identified using a traditional systematic database search. This strategy was supplemented with iterative searches. Results: Searches yielded 3172 citations, and 28 articles with sufficient information were included to develop the emerging theories. Four evidence-informed theories were developed proposing ways in which a safe and supportive environment for the disclosure of SV is enabled in SRHS. The theories consider how interventions may overcome barriers surrounding SV disclosure at individual, service-delivery and societal levels. Conclusions: Benefits of SRHS engagement with health promotion and health activism activities to address societal level barriers like lack of service awareness and stereotypic views on SV are presented. Although trauma informed practice and person-centred care were central in creating a safe and supportive environment for disclosure the review found them to be poorly defined in this setting.

Sibling Experiences of Adverse Childhood Experiences: A Scoping Review.

Adverse childhood experiences (ACEs) are traumatic events during childhood known to affect health and well-being across the life span. The detrimental impact ACEs have on children and young people is well-established. It is also known that 85 to 90% of children have at least one sibling. Using this as the foundation for our inquiry, the purpose of this scoping review was to understand what we currently know about the experiences of siblings living with ACEs. Sibling relationships are unique, and for some the most enduring of experiences. These relationships can be thought of as bonds held together by love and warmth; however, they can also provide scope for undesirable outcomes, such as escalation of conflicts and animosities. This scoping review was conducted following Arksey and O'Malley's (2005) methodological framework, complemented by the PAGER framework (Bradbury-Jones et al. 2021), offering a structured approach to the review's analysis and reporting through presenting the Patterns, Advances, Gaps, and Evidence for practice and Research. In June 2020, we searched 12 databases, with 11,469 results. Articles were screened for eligibility by the review team leaving a total of 148 articles meeting the inclusion criteria. Included articles highlighted overwhelming evidence of older siblings shielding younger siblings, and the likelihood that when one sibling experiences adversity, other siblings will be experiencing it themselves or vicariously. The implications of this in practice are that support services and statutory bodies need to ensure considerations are given to all siblings when one has presented with experiencing childhood adversity, especially to older siblings who may take far more burden as regards care-giving and protection of younger siblings. Given that more than half of the included articles did not offer any theoretical understanding to sibling experiences of ACEs, this area is of importance for future research. Greater attention is also needed for research exploring different types of sibling relationships (full, step, half), and whether these influence the impact that ACEs have on children and young people.

A Scoping Review on Sexual and Gender-Based Violence Medicolegal Service Provision in East Africa.

Sexual and gender-based violence (SGBV) is a leading cause of physical, emotional, and psychosocial problems around the world, with many countries in East Africa having rates above the global average. Despite the high prevalence in the region, service provision for post-SGBV care is often poorly funded, difficult to access, or simply nonexistent. This review reports the findings of a scoping review of literature from East Africa. The goals of this research were to evaluate existing service provision practices throughout the region, understand how provider bias may affect service provision, and compare existing practices to national policies and internationally agreed human rights treaties. This review identified 54 academic papers and reports through a search of electronic databases and grey literature sources, and four main themes emerged: (1) current models of service provision are inadequate to address the medical and psychosocial needs of survivors; (2) countries are not providing sufficient funding for services; (3) further research is needed into how to incorporate SGBV care into existing health systems and align with international human rights treaties; and (4) there is limited research in many countries in East Africa. The findings are likely to be of use to policy makers, nongovernmental organizations, and service providers working in the medical, legal, and justice systems.

The Experiences of Post-Separation Survivors of Domestic Violence During the Covid-19 Pandemic: Findings From a Qualitative Study in the United Kingdom.

Post-separation for domestic violence (DV) survivors is known to be a period of heightened risk of domestic homicide. Evidence points to increased rates of DV during the Covid-19 pandemic, with specific challenges in help-seeking from DV services, yet studies that capture this qualitatively are still emerging. This UK study investigated the experiences of 21 separated DV survivors (all women) during the Covid-19 pandemic. Inductive, thematic analysis highlighted participants' psychological distress, isolation, fear of Covid-19 transmission, and detachment from support networks. The findings reflect the interconnected nature of adversities experienced by DV survivors and the exacerbation of these due to the insidious, multifaceted, and synergistic impacts of DV and the pandemic.

Improving the visibility and description of theory in qualitative research: The QUANTUM typology.

The relationship between theory and qualitative research has been much debated. In 2014, based on an analysis of qualitative studies, we published a five-point typology on the levels of visibility expounded in such studies. The typology captured a range of theoretical visibility - from seemingly absent to consistently applied. In 2020, we undertook a project to critique and revise the typology, guided by the ADAPT-ITT framework. ADAPT-ITT was developed originally to inform the adaptation of evidence-based interventions to new geographic regions, cultural contexts or populations related to HIV. It has subsequently evolved as a helpful framework in a number of health and social fields. The ADAPT-ITT framework provides a systematic, stepwise process that allows existing interventions to be adapted, rather than creating new interventions unnecessarily. The use of ADAPT-ITT to guide the adaptation of a methodological framework (as opposed to a health intervention) is novel and we used it flexibly, as reported in this article. Core to this process was the engagement of 14 international qualitative research experts, drawn mainly from health and social science disciplines. The outcome was a revised typology, presented in this article. We offer this as a reflexive aide for the conduct and reporting of qualitative research.

Impacts of an Intervention to Improve the Identification, Referral and Safety of Those Experiencing Domestic Violence: A Mixed Methods Study in the UK.

This study is the first evaluation of the impacts on long-term health issues (and associations with ethnicity and poverty) of a domestic violence intervention, Identification and Referral to Improve Safety (IRIS). IRIS is a domestic violence training, support and referral programme based mainly in primary care settings. This was a convergent, parallel, mixed methods UK study. In the quantitative phase, we matched the health records of 294 patients who had a marker for domestic violence with records from a domestic violence support service to track the health conditions of participants before and after referral to IRIS. In the qualitative phase, we conducted semi-structured telephone interviews with 21 women who had received IRIS support and thematically analysed the data. Descriptive statistics indicated that, at the point of referral to IRIS, participants had a variety of health conditions, with a reduction on a number of mental and overall physical health conditions post-IRIS. Qualitative data are reported under five prominent themes: life before, driving forces for help-seeking, experiences of support, perceived impacts and recovery as a journey. Overall, we found that IRIS support was associated with a positive impact on participants. The study highlights the benefits of improved identification and referral of domestic violence survivors.

Association between childhood maltreatment and atopy in the UK: A population based retrospective cohort study.

Background: Childhood maltreatment affects over one in three children worldwide and is associated with a substantial disease burden. This study explores the association between childhood maltreatment and the development of atopic disease. Methods: We did a population-based retrospective matched open cohort study using participating general practices between 1st January 1995 and 30th September 2019. Read codes were utilised to identify patients exposed to childhood maltreatment (either suspected or confirmed) who were matched to up to four unexposed patients by age, sex, general practice, and Townsend deprivation quintile. Cox regression analysis was used to calculate adjusted (age, sex, Townsend deprivation quintile) hazard ratios (aHR) for development of atopy (asthma, atopic dermatitis, or allergic rhino conjunctivitis) during follow up in those without atopy at study entry. Results: 183,897 exposed patients were matched to 621,699 unexposed patients. During the follow up period, 18,555 patients (incidence rate (IR) 28.18 per 1000 person-years) in the exposed group developed atopic disease compared to the 68,368 (IR 23.58 per 1000 person-years) in the unexposed group, translating to an adjusted HR of 1.14 (95% CI 1.12-1.15). Notably, the risk of developing asthma was aHR 1.42 (95% CI 1.37-1.46). Associations were more pronounced in analyses restricted to females and confirmed cases of childhood maltreatment only. Interpretation: Considering the substantial health burden associated with childhood maltreatment, it is important to implement public health policies aimed at enhancing: 1) detection and primary prevention of childhood maltreatment, 2) secondary and tertiary prevention interventions to reduce the burden of ill health associated with exposure to maltreatment and 3) clinical awareness of such associations and subsequent knowledge of management. Funding: None.

Domestic Abuse Sibling studY (DASY): a multimethod study protocol.

INTRODUCTION: Domestic violence and abuse (DVA) is an everyday aspect of many children and young people's lives, both in the home and in their own relationships. Studies estimate that up to one million children and young people experience some form of DVA each year in the UK. Although the majority of families experiencing DVA have more than one child, most research to date has focused on individual children within these families. This study aims to explore the views of practitioners, parent/carers and young people on sibling responses in the context and aftermath of DVA. Our protocol has followed SPIRIT guidelines. METHODS AND ANALYSIS: We propose a multimethod study consisting of semistructured interviews, the completion of Sibling Relationship Questionnaires, photovoice interviews and illustrative case studies to explore sibling experiences in the context and aftermath of DVA. A purposive sample of front-line practitioner participants will be recruited and interviewed first. We will ask them to introduce us to parent/carer and young people participants using a snowball approach (n=70). Qualitative data will be analysed through reflexive thematic analysis, theoretically underpinned by critical realism, to explore patterns in participants' views and experiences of siblings in the context and aftermath of DVA. Quantitative data collected from the Sibling Relationship Questionnaire's four domains (warmth/closeness, power/status, conflict and rivalry) will be analysed. Data triangulation of the quantitative and qualitative data within this study will occur at the results interpretation stage. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the University of Birmingham Research Ethic Committee (ERN_21-0795). Findings will be published in open access peer-reviewed journals and presented at relevant conferences and events. Child-facing infographics and front-line practitioner guides will also be produced.

How do nurses and midwives perceive their role in sexual healthcare?

BACKGROUND: Nurses and midwives role in sexual healthcare is essential to help patients, particularly women, ensure a satisfactory sexual wellbeing. Yet, these professionals often overlook this aspect of patients' health. Little is known regarding nurses and midwives' attitudes, views and experiences concerning sexual healthcare. Using a naturalistic inquiry approach, this qualitative study was conducted to overcome this limitation and gain insights into nurses and midwives' role in the delivery of sexual healthcare. METHODS: A purposive sample of nurses and midwives was chosen from different clinical sites. Data generated by focus group discussions were were analysed using the Framework Analysis while adopting different strategies to ensure rigour. The study aligns with the consolidated criteria for reporting qualitative research checklist. RESULTS: Five themes illustrated the participants' views and experiences. These are: 'Perceptions of sexuality', 'Appreciating the discussion around the individuals' sexual issues', 'Muting the discussion around the individuals' sexual issues, 'Coping with embarrassment', and 'Promoting nurses' and midwives' roles sexual healthcare'. Nurses and midwives discussed the importance of sexuality in the couple's life. They reported controversial views and highlighted many challenges that make them reluctant in playing an efficient role in sexual healthcare. They discussed many suggestions, mainly getting a solid sexual health education to become better equipped to meet patients' sexual health needs. CONCLUSION: Findings are critical to empower nurses and midwives, break the barriers in discussing sexual healthcare and integrate this aspects of care more actively and confidently in daily practice.