Feasibility of a reconfigured domestic violence and abuse training and support intervention responding to affected women, men, children and young people through primary care.

BACKGROUND: Identification in UK general practice of women affected by domestic violence and abuse (DVA) is increasing, but men and children/young people (CYP) are rarely identified and referred for specialist support. To address this gap, we collaborated with IRISi (UK social enterprise) to strengthen elements of the IRIS + intervention which included the identification of men, direct engagement with CYP, and improved guidance on responding to information received from other agencies. IRIS + was an adaptation of the national IRIS (Identification and Referral to Improve Safety) model focused on the needs of women victim-survivors of DVA. Without diminishing the responses to women, IRIS + also responded to the needs of men experiencing or perpetrating DVA, and CYP living with DVA and/or experiencing it in their own relationships. Our study tested the feasibility of the adapted IRIS + intervention in England and Wales between 2019-21. METHODS: We used mixed method analysis to triangulate data from various sources (pre/post intervention questionnaires with primary care clinicians; data extracted from medical records and DVA agencies; semi-structured interviews with clinicians, service providers and referred adults and children) to assess the feasibility and acceptability of the IRIS + intervention. RESULTS: The rate of referral for women doubled (21.6/year/practice) from the rate (9.29/year/practice) in the original IRIS trial. The intervention also enabled identification and direct referral of CYP (15% of total referrals) and men (mostly survivors, 10% of total referrals). Despite an increase in self-reported clinician preparedness to respond to all patient groups, the intervention generated a low number of men perpetrator referrals (2% of all referrals). GPs were the principal patient referrers. Over two-thirds of referred women and CYP and almost half of all referred men were directly supported by the service. Many CYP also received IRIS + support indirectly, via the referred parents. Men and CYP supported by IRIS + reported improved physical and mental health, wellbeing, and confidence. CONCLUSIONS: Although the study showed acceptability and feasibility, there remains uncertainty about the effectiveness, cost-effectiveness, and scalability of IRIS + . Building on the success of this feasibility study, the next step should be trialling the effectiveness of IRIS + implementation to inform service implementation decisions.

Primary care system-level training and support programme for the secondary prevention of domestic violence and abuse: a cost-effectiveness feasibility model.

OBJECTIVES: This study aimed to evaluate the prospective cost-effectiveness of the Identification and Referral to Improve Safety plus (IRIS+) intervention compared with usual care using feasibility data derived from seven UK general practice sites. METHOD: A cost-utility analysis was conducted to assess the potential cost-effectiveness of IRIS+, an enhanced model of the UK's usual care. IRIS+ assisted primary care staff in identifying, documenting and referring not only women, but also men and children who may have experienced domestic violence/abuse as victims, perpetrators or both. A perpetrator group programme was not part of the intervention per se but was linked to the IRIS+ intervention via a referral pathway and signposting. A Markov model was constructed from a societal perspective to estimate mean incremental costs and quality-adjusted life years (QALYs) of IRIS+ compared with to usual care over a 10-year time horizon. RESULTS: The IRIS+ intervention saved £92 per patient and produced QALY gains of 0.003. The incremental net monetary benefit was positive (£145) and the IRIS+ intervention was cost-effective in 55% of simulations at a cost-effectiveness threshold of £20 000 per QALY. CONCLUSION: The IRIS+ intervention could be cost-effective or even cost saving from a societal perspective in the UK, though there are large uncertainties, reflected in the confidence intervals and simulation results.

Dentistry responding in domestic violence and abuse (DRiDVA) feasibility study: a qualitative evaluation of the implementation experiences of dental professionals.

BACKGROUND: Domestic Violence and Abuse (DVA) is a persistent public health problem in the UK. Healthcare settings offer an opportunity to ask patients about DVA, either opportunistically or in response to the presence of injuries. However, it has been suggested that dental practices and dental teams have not been actively involved supporting adult patients when presenting with injuries that might have resulted from DVA. This qualitative study was conducted to satisfy the evaluative component of the Dentistry Responding in Domestic Violence and Abuse (DRiDVA) feasibility study. METHODS: In total, 30 participants took part in the study; nine associate dentists and practice principals/owners took part in one-to-one interviews and 21 auxiliary staff took part across two focus group discussion sessions. Data were analysed using the seven step Framework Analysis process. RESULT: Three key themes were identified from the data, focusing on barriers to enquiring about domestic violence and abuse, Facilitators of identification and referral of DVA in dental settings, and recommendations for further adaptation of intervention to dental settings. CONCLUSION: DVA training coupled with robust referral pathways to a named specialist DVA advocate increases knowledge and awareness of the signs of DVA and confidence in making onward referrals. Further research is needed to understand how to increase dental professional willingness to ask patients about DVA.

Adapting domestic abuse training to remote delivery during the COVID-19 pandemic: a qualitative study of views from general practice and support services.

BACKGROUND: Identifying and responding to patients affected by domestic violence and abuse (DVA) is vital in primary care. There may have been a rise in the reporting of DVA cases during the COVID-19 pandemic and associated lockdown measures. Concurrently general practice adopted remote working that extended to training and education. IRIS (Identification and Referral to Improve Safety) is an example of an evidence-based UK healthcare training support and referral programme, focusing on DVA. IRIS transitioned to remote delivery during the pandemic. AIM: To understand the adaptations and impact of remote DVA training in IRIS-trained general practices by exploring perspectives of those delivering and receiving training. DESIGN AND SETTING: Qualitative interviews and observation of remote training of general practice teams in England were undertaken. METHOD: Semi-structured interviews were conducted with 21 participants (three practice managers, three reception and administrative staff, eight general practice clinicians, and seven specialist DVA staff), alongside observation of eight remote training sessions. Analysis was conducted using a framework approach. RESULTS: Remote DVA training in UK general practice widened access to learners. However, it may have reduced learner engagement compared with face-to-face training and may challenge safeguarding of remote learners who are domestic abuse survivors. DVA training is integral to the partnership between general practice and specialist DVA services, and reduced engagement risks weakening this partnership. CONCLUSION: The authors recommend a hybrid DVA training model for general practice, including remote information delivery alongside a structured face-to-face element. This has broader relevance for other specialist services providing training and education in primary care.

Dentistry responding to domestic violence and abuse: a dental, practice-based intervention and a feasibility study for a cluster randomised trial.

Objectives Assess the feasibility of using the Identification and Referral to Improve Safety (IRIS) intervention in a general dental practice setting and evaluating it using a cluster randomised trial design. IRIS is currently used in general medical practices to aid recognition and support referral into specialist support of adults presenting with injuries and other presenting factors that might have resulted from domestic violence and abuse. Also, to explore the feasibility of a cluster randomised trial design to evaluate the adapted IRIS.Design Feasibility study for a cluster randomised trial of a practice-based intervention.Setting Greater Manchester general dental practices.Results It was feasible to adapt the IRIS intervention used in general medical practices to general dental practices in terms of training the clinical team and establishing a direct referral pathway to a designated advocate educator. General dental practices were keen to adopt the intervention, discuss with patients when presented with the opportunity and utilise the referral pathway. However, we could not use practice IT software prompts and data collection as for general practitioners because there is no unified dental IT system and because coding in dentistry for diagnoses, procedures and outcomes is not developed in the UK.Conclusion While it was feasible to adapt elements of the IRIS intervention to general dental practice and there was general acceptability, we did not have enough empirical data to plan a definitive cluster randomised trial design to evaluate the IRIS-dentistry intervention within general dental practices.

Impact of the first national COVID-19 lockdown on referral of women experiencing domestic violence and abuse in England and Wales.

BACKGROUND: The lockdown periods to curb COVID-19 transmission have made it harder for survivors of domestic violence and abuse (DVA) to disclose abuse and access support services. Our study describes the impact of the first COVID-19 wave and the associated national lockdown in England and Wales on the referrals from general practice to the Identification and Referral to Improve Safety (IRIS) DVA programme. We compare this to the change in referrals in the same months in the previous year, during the school holidays in the 3 years preceding the pandemic and the period just after the first COVID-19 wave. School holiday periods were chosen as a comparator, since families, including the perpetrator, are together, affecting access to services. METHODS: We used anonymised data on daily referrals received by the IRIS DVA service in 33 areas from general practices over the period April 2017-September 2020. Interrupted-time series and non-linear regression were used to quantify the impact of the first national lockdown in March-June 2020 comparing analogous months the year before, and the impact of school holidays (01/04/2017-30/09/2020) on number of referrals, reporting Incidence Rate Ratio (IRR), 95% confidence intervals and p-values. RESULTS: The first national lockdown in 2020 led to reduced number of referrals to DVA services (27%, 95%CI = (21,34%)) compared to the period before and after, and 19% fewer referrals compared to the same period in the year before. A reduction in the number of referrals was also evident during the school holidays with the highest reduction in referrals during the winter 2019 pre-pandemic school holiday (44%, 95%CI = (32,54%)) followed by the effect from the summer of 2020 school holidays (20%, 95%CI = (10,30%)). There was also a smaller reduction (13-15%) in referrals during the longer summer holidays 2017-2019; and some reduction (5-16%) during the shorter spring holidays 2017-2019. CONCLUSIONS: We show that the COVID-19 lockdown in 2020 led to decline in referrals to DVA services. Our findings suggest an association between decline in referrals to DVA services for women experiencing DVA and prolonged periods of systemic closure proxied here by both the first COVID-19 national lockdown or school holidays. This highlights the need for future planning to provide adequate access and support for people experiencing DVA during future national lockdowns and during the school holidays.

PRimary care rEsponse to domestic violence and abuse in the COvid-19 panDEmic (PRECODE): protocol of a rapid mixed-methods study in the UK.

BACKGROUND: The implementation of lockdowns in the UK during the COVID-19 pandemic resulted in a system switch to remote primary care consulting at the same time as the incidence of domestic violence and abuse (DVA) increased. Lockdown-specific barriers to disclosure of DVA reduced the opportunity for DVA detection and referral. The PRECODE (PRimary care rEsponse to domestic violence and abuse in the COvid-19 panDEmic) study will comprise quantitative analysis of the impact of the pandemic on referrals from IRIS (Identification and Referral to Improve Safety) trained general practices to DVA agencies in the UK and qualitative analysis of the experiences of clinicians responding to patients affected by DVA and adaptations they have made transitioning to remote DVA training and patient support. METHODS/DESIGN: Using a rapid mixed method design, PRECODE will explore and explain the dynamics of DVA referrals and support before and during the pandemic on a national scale using qualitative data and over four years of referrals time series data. We will undertake interrupted-time series and non-linear regression analysis, including sensitivity analyses, on time series of referrals to DVA services from routinely collected data to evaluate the impact of the pandemic and associated lockdowns on referrals to the IRIS Programme, and analyse key determinants associated with changes in referrals. We will also conduct an interview- and observation-based qualitative study to understand the variation, relevance and feasibility of primary care responses to DVA before and during the pandemic and its aftermath. The triangulation of quantitative and qualitative findings using rapid analysis and synthesis will enable the articulation of multiscale trends in primary care responses to DVA and complex mechanisms by which these responses have changed during the pandemic. DISCUSSION: Our findings will inform the implementation of remote primary care and DVA service responses as services re-configure. Understanding the adaptation of clinical and service responses to DVA during the pandemic is crucial for the development of evidence-based, effective remote support and referral beyond the pandemic. TRIAL REGISTRATION: PRECODE is an observational epidemiologic study, not an intervention evaluation or trial. We will not be reporting results of an intervention on human participants.

Disruption of a primary health care domestic violence and abuse service in two London boroughs: interrupted time series evaluation.

BACKGROUND: Domestic violence and abuse (DVA) is experienced by about 1/3 of women globally and remains a major health concern worldwide. IRIS (Identification and Referral to Improve Safety of women affected by DVA) is a complex, system-level, training and support programme, designed to improve the primary healthcare response to DVA. Following a successful trial in England, since 2011 IRIS has been implemented in eleven London boroughs. In two boroughs the service was disrupted temporarily. This study evaluates the impact of that service disruption. METHODS: We used anonymised data on daily referrals received by DVA service providers from general practices in two IRIS implementation boroughs that had service disruption for a period of time (six and three months). In line with previous work we refer to these as boroughs B and C. The primary outcome was the number of daily referrals received by the DVA service provider across each borough over 48 months (March 2013-April 2017) in borough B and 42 months (October 2013-April 2017) in borough C. The data were analysed using interrupted-time series, non-linear regression with sensitivity analyses exploring different regression models. Incidence Rate Ratio (IRR), 95% confidence intervals and p-values associated with the disruption were reported for each borough. RESULTS: A mixed-effects negative binomial regression was the best fit model to the data. In borough B, the disruption, lasted for about six months, reducing the referral rate significantly (p = 0.006) by about 70% (95%CI = (23,87%)). In borough C, the three-month service disruption, also significantly (p = 0.005), reduced the referral rate by about 49% (95% CI = (18,68%)). CONCLUSIONS: Disrupting the IRIS service substantially reduced the rate of referrals to DVA service providers. Our findings are evidence in favour of continuous funding and staffing of IRIS as a system level programme.

Improving the healthcare response to domestic violence and abuse in UK primary care: interrupted time series evaluation of a system-level training and support programme.

BACKGROUND: It is unknown whether interventions known to improve the healthcare response to domestic violence and abuse (DVA)-a global health concern-are effective outside of a trial. METHODS: An observational interrupted time series study in general practice. All registered women aged 16 and above were eligible for inclusion. In four implementation boroughs' general practices, there was face-to-face, practice-based, clinically relevant DVA training, a prompt in the electronic medical record, reminding clinicians to consider DVA, a simple referral pathway to a named advocate, ensuring direct access for women to specialist services, overseen by a national, health-focused DVA organisation, fostering best practice. The fifth comparator borough had only a session delivered by a local DVA specialist agency at community venues conveying information to clinicians. The primary outcome was the daily number of referrals received by DVA workers per 1000 women registered in a general practice, from 205 general practices, in all five northeast London boroughs. The secondary outcome was recorded new DVA cases in the electronic medical record in two boroughs. Data was analysed using an interrupted time series with a mixed effects Poisson regression model. RESULTS: In the 144 general practices in the four implementation boroughs, there was a significant increase in referrals received by DVA workers-global incidence rate ratio of 30.24 (95% CI 20.55 to 44.77, p < 0.001). There was no increase in the 61 general practices in the other comparator borough (incidence rate ratio of 0.95, 95% CI 0.13 to 6.84, p = 0.959). New DVA cases recorded significantly increased with an incident rate ratio of 1.27 (95% CI 1.09 to 1.48, p < 0.002) in the implementation borough but not in the comparator borough (incidence rate ratio of 1.05, 95% CI 0.82 to 1.34, p = 0.699). CONCLUSIONS: Implementing integrated referral routes, training and system-level support, guided by a national health-focused DVA organisation, outside of a trial setting, was effective and sustainable at scale, over four years (2012 to 2017) increasing referrals to DVA workers and new DVA cases recorded in electronic medical records.

Improving the healthcare response to domestic violence and abuse in primary care: protocol for a mixed method evaluation of the implementation of a complex intervention.

BACKGROUND: Domestic violence and abuse remains a major health concern. It is unknown whether the improved healthcare response to domestic violence and abuse demonstrated in a cluster randomised controlled trial of IRIS (Identification and Referral to Improve Safety), a complex intervention, including general practice based training, support and referral programme, can be achieved outside a trial setting. AIM: To evaluate the impact over four years of a system wide implementation of IRIS, sequentially into multiple areas, outside the setting of a trial. METHODS: An interrupted time series analysis of referrals received by domestic violence and abuse workers from 201 general practices, in five northeast London boroughs; alongside a mixed methods process evaluation and qualitative analysis. Segmented regression interrupted time series analysis to estimate impact of the IRIS intervention over a 53-month period. A secondary analysis compares the segmented regression analysis in each of the four implementation boroughs, with a fifth comparator borough. DISCUSSION: This is the first interrupted time series analysis of an intervention to improve the health care response to domestic violence. The findings will characterise the impact of IRIS implementation outside a trial setting and its suitability for national implementation in the United Kingdom.

Cost-effectiveness of a domestic violence and abuse training and support programme in primary care in the real world: updated modelling based on an MRC phase IV observational pragmatic implementation study.

OBJECTIVES: To evaluate the cost-effectiveness of the implementation of the Identification and Referral to Improve Safety (IRIS) programme using up-to-date real-world information on costs and effectiveness from routine clinical practice. A Markov model was constructed to estimate mean costs and quality-adjusted life-years (QALYs) of IRIS versus usual care per woman registered at a general practice from a societal and health service perspective with a 10-year time horizon. DESIGN AND SETTING: Cost-utility analysis in UK general practices, including data from six sites which have been running IRIS for at least 2 years across England. PARTICIPANTS: Based on the Markov model, which uses health states to represent possible outcomes of the intervention, we stipulated a hypothetical cohort of 10 000 women aged 16 years or older. INTERVENTIONS: The IRIS trial was a randomised controlled trial that tested the effectiveness of a primary care training and support intervention to improve the response to women experiencing domestic violence and abuse, and found it to be cost-effective. As a result, the IRIS programme has been implemented across the UK, generating data on costs and effectiveness outside a trial context. RESULTS: The IRIS programme saved £14 per woman aged 16 years or older registered in general practice (95% uncertainty interval -£151 to £37) and produced QALY gains of 0.001 per woman (95% uncertainty interval -0.005 to 0.006). The incremental net monetary benefit was positive both from a societal and National Health Service perspective (£42 and £22, respectively) and the IRIS programme was cost-effective in 61% of simulations using real-life data when the cost-effectiveness threshold was £20 000 per QALY gained as advised by National Institute for Health and Care Excellence. CONCLUSION: The IRIS programme is likely to be cost-effective and cost-saving from a societal perspective in the UK and cost-effective from a health service perspective, although there is considerable uncertainty surrounding these results, reflected in the large uncertainty intervals.

Modified African Ngoma Healing Ceremony for Stress Reduction: A Pilot Study.

OBJECTIVE: Indigenous people's ceremonies using rhythm and dance have been used for countless generations throughout the world for healing, conflict resolution, social bonding, and spiritual experience. A previous study reported that a ceremony based on the Central African ngoma tradition was favorably received by a group of Americans. The present trial compared the effects of the modified ngoma ceremony (Ngoma) with those of mindfulness-based stress reduction (MBSR) in a randomized pilot study. METHODS: Twenty-one women were randomized to either Ngoma or MBSR. Both groups had sessions on a weekly basis for 8 weeks and completed questionnaires at baseline, week 8, and 1 month after the intervention. Participants completed questionnaires, which included self-report of depressive and anxiety symptoms, health status (e.g., quality of life and functioning), social bonding, and perception of the credibility of the two interventions. RESULTS: Both groups showed improvements in depression, anxiety, emotional well being, and social functioning as measured by respective scales. Social bonding also increased in both groups during the study and may be a mechanism for both interventions. Participants found both interventions credible. CONCLUSIONS: In this pilot study, Ngoma showed significant and durable beneficial effects comparable to MBSR. The effects of Ngoma and other indigenous rhythm-dance ceremonies on distress and health status in western culture should be investigated in larger clinical studies.

Women's experiences of referral to a domestic violence advocate in UK primary care settings: a service-user collaborative study.

BACKGROUND: Women experiencing domestic violence and abuse (DVA) are more likely to be in touch with health services than any other agency, yet doctors and nurses rarely ask about abuse, often failing to identify signs of DVA in their patients. AIM: To understand women's experience of disclosure of DVA in primary care settings and subsequent referral to a DVA advocate in the context of a DVA training and support programme for primary care clinicians: Identification and Referral to Improve Safety (IRIS). DESIGN AND SETTING: A service-user collaborative study using a qualitative study design. Recruitment was from across IRIS trial settings in Bristol and Hackney, London. METHOD: Twelve women who had been referred to one of two specialist DVA advocates (based at specialist DVA agencies) were recruited by a GP taking part in IRIS. Women were interviewed by a survivor of DVA and interviews were recorded and transcribed verbatim. Analysis was thematic using constant comparison. RESULTS: GPs and nurses can play an important role in identifying women experiencing DVA and referring them to DVA specialist agencies. GPs may also have an important role to play in helping women maintain any changes they make as a result of referral to an advocate, by asking about DVA in subsequent consultations. CONCLUSION: A short time interval between a primary care referral and initial contact with an advocate was valued by some women. For the initial contact with an advocate to happen as soon as possible after a primary care referral has been made, a close working relationship between primary care and the third sector needs to be cultivated.

Identification and Referral to Improve Safety (IRIS) of women experiencing domestic violence with a primary care training and support programme: a cluster randomised controlled trial.

BACKGROUND: Most clinicians have no training about domestic violence, fail to identify patients experiencing abuse, and are uncertain about management after disclosure. We tested the effectiveness of a programme of training and support in primary health-care practices to increase identification of women experiencing domestic violence and their referral to specialist advocacy services. METHODS: In this cluster randomised controlled trial, we selected general practices in two urban primary care trusts, Hackney (London) and Bristol, UK. Practices in which investigators from this trial were employed or those who did not use electronic records were excluded. Practices were stratified by proportion of female doctors, postgraduate training status, number of patients registered, and percentage of practice population on low incomes. Within every primary care trust area, we randomised practices with a computer-minimisation programme with a random component to intervention or control groups. The intervention programme included practice-based training sessions, a prompt within the medical record to ask about abuse, and a referral pathway to a named domestic violence advocate, who also delivered the training and further consultancy. The primary outcome was recorded referral of patients to domestic violence advocacy services. The prespecified secondary outcome was recorded identification of domestic violence in the electronic medical records of the general practice. Poisson regression analyses accounting for clustering were done for all practices receiving the intervention. Practice staff and research associates were not masked and patients were not aware they were part of a study. This study is registered at Current Controlled Trials, ISRCTN74012786. FINDINGS: We randomised 51 (61%) of 84 eligible general practices in Hackney and Bristol. Of these, 24 received a training and support programme, 24 did not receive the programme, and three dropped out before the trial started. 1 year after the second training session, the 24 intervention practices recorded 223 referrals of patients to advocacy and the 24 control practices recorded 12 referrals (adjusted intervention rate ratio 22·1 [95% CI 11·5-42·4]). Intervention practices recorded 641 disclosures of domestic violence and control practices recorded 236 (adjusted intervention rate ratio 3·1 [95% CI 2·2-4·3). No adverse events were recorded. INTERPRETATION: A training and support programme targeted at primary care clinicians and administrative staff improved referral to specialist domestic violence agencies and recorded identification of women experiencing domestic violence. Our findings reduce the uncertainty about the benefit of training and support interventions in primary care settings for domestic violence and show that screening of women patients for domestic violence is not a necessary condition for improved identification and referral to advocacy services. FUNDING: Health Foundation.

Primary care identification and referral to improve safety of women experiencing domestic violence (IRIS): protocol for a pragmatic cluster randomised controlled trial.

BACKGROUND: Domestic violence, which may be psychological, physical, sexual, financial or emotional, is a major public health problem due to the long-term health consequences for women who have experienced it and for their children who witness it. In populations of women attending general practice, the prevalence of physical or sexual abuse in the past year from a partner or ex-partner ranges from 6 to 23%, and lifetime prevalence from 21 to 55%. Domestic violence is particularly important in general practice because women have many contacts with primary care clinicians and because women experiencing abuse identify doctors and nurses as professionals from whom they would like to get support. Yet health professionals rarely ask about domestic violence and have little or no training in how to respond to disclosure of abuse. METHODS/DESIGN: This protocol describes IRIS, a pragmatic cluster randomised controlled trial with the general practice as unit of randomisation. Our trial tests the effectiveness and cost-effectiveness of a training and support programme targeted at general practice teams. The primary outcome is referral of women to specialist domestic violence agencies. Forty-eight practices in two UK cities (Bristol and London) are randomly allocated, using minimisation, into intervention and control groups. The intervention, based on an adult learning model in an educational outreach framework, has been designed to address barriers to asking women about domestic violence and to encourage appropriate responses to disclosure and referral to specialist domestic violence agencies. Multidisciplinary training sessions are held with clinicians and administrative staff in each of the intervention practices, with periodic feedback of identification and referral data to practice teams. Intervention practices have a prompt to ask about abuse integrated in the electronic medical record system. Other components of the intervention include an IRIS champion in each practice and a direct referral pathway to a named domestic violence advocate. DISCUSSION: This is the first European randomised controlled trial of an intervention to improve the health care response to domestic violence. The findings will have the potential to inform training and service provision. TRIAL REGISTRATION: ISRCTN74012786.