Randomised pilot and feasibility trial of a group intervention for men who perpetrate intimate partner violence against women.

BACKGROUND: There is a need for robust evidence on the effectiveness and cost-effectiveness of domestic abuse perpetrator programmes in reducing abusive behaviour and improving wellbeing for victim/survivors. While any randomised controlled trial can present difficulties in terms of recruitment and retention, conducting such a trial with domestic abuse perpetrators is particularly challenging. This paper reports the pilot and feasibility trial of a voluntary domestic abuse perpetrator group programme in the United Kingdom. METHODS: This was a pragmatic individually randomised pilot and feasibility trial with an integrated qualitative study in one site (covering three local-authority areas) in England. Male perpetrators were randomised to either the intervention or usual care. The intervention was a 23-week group programme for male perpetrators in heterosexual relationships, with an average of three one-to-one sessions, and one-to-one support for female current- or ex-partners delivered by third sector organisations. There was no active control treatment for men, and partners of control men were signposted towards domestic abuse support services. Data were collected at three-monthly intervals for nine months from male and female participants. The main objectives assessed were recruitment, randomisation, retention, data completeness, fidelity to the intervention model, and acceptability of the trial design. RESULTS: This study recruited 36 men (22 randomly allocated to attend the intervention group programme, 14 to usual care), and 15 current- or ex-partners (39% of eligible partners). Retention and completeness of data were high: 67% of male (24/36), and 80% (12/15) of female participants completed the self-reported questionnaire at nine months. A framework for assessing fidelity to the intervention was developed. In interviews, men who completed all or most of the intervention gave positive feedback and reported changes in their own behaviour. Partners were also largely supportive of the trial and were positive about the intervention. Participants who were not allocated to the intervention group reported feeling disappointed but understood the rationale for the trial. CONCLUSIONS: It was feasible to recruit, randomise and retain male perpetrators and female victim/survivors of abuse and collect self-reported outcome data. Participants were engaged in the intervention and reported positive benefits. The trial design was seen as acceptable. TRIAL REGISTRATION: ISRCTN71797549, submitted 03/08/2017, retrospectively registered 27/05/2022.

Psychosocial interventions for survivors of rape and sexual assault experienced during adulthood.

BACKGROUND: Exposure to rape, sexual assault and sexual abuse has lifelong impacts for mental health and well-being. Prolonged Exposure (PE), Cognitive Processing Therapy (CPT) and Eye Movement Desensitisation and Reprocessing (EMDR) are among the most common interventions offered to survivors to alleviate post-traumatic stress disorder (PTSD) and other psychological impacts. Beyond such trauma-focused cognitive and behavioural approaches, there is a range of low-intensity interventions along with new and emerging non-exposure based approaches (trauma-sensitive yoga, Reconsolidation of Traumatic Memories and Lifespan Integration). This review presents a timely assessment of international evidence on any type of psychosocial intervention offered to individuals who experienced rape, sexual assault or sexual abuse as adults. OBJECTIVES: To assess the effects of psychosocial interventions on mental health and well-being for survivors of rape, sexual assault or sexual abuse experienced during adulthood. SEARCH METHODS: In January 2022, we searched CENTRAL, MEDLINE, Embase, 12 other databases and three trials registers. We also checked reference lists of included studies, contacted authors and experts, and ran forward citation searches. SELECTION CRITERIA: Any study that allocated individuals or clusters of individuals by a random or quasi-random method to a psychosocial intervention that promoted recovery and healing following exposure to rape, sexual assault or sexual abuse in those aged 18 years and above compared with no or minimal intervention, usual care, wait-list, pharmacological only or active comparison(s). We classified psychosocial interventions according to Cochrane Common Mental Disorders Group's psychological therapies list. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. MAIN RESULTS: We included 36 studies (1991 to 2021) with 3992 participants randomly assigned to 60 experimental groups (3014; 76%) and 23 inactive comparator conditions (978, 24%). The experimental groups consisted of: 32 Cognitive Behavioural Therapy (CBT); 10 behavioural interventions; three integrative therapies; three humanist; five other psychologically oriented interventions; and seven other psychosocial interventions. Delivery involved 1 to 20 (median 11) sessions of traditional face-to-face (41) or other individual formats (four); groups (nine); or involved computer-only interaction (six). Most studies were conducted in the USA (n = 26); two were from South Africa; two from the Democratic Republic of the Congo; with single studies from Australia, Canada, the Netherlands, Spain, Sweden and the UK. Five studies did not disclose a funding source, and all disclosed sources were public funding. Participants were invited from a range of settings: from the community, through the media, from universities and in places where people might seek help for their mental health (e.g. war veterans), in the aftermath of sexual trauma (sexual assault centres and emergency departments) or for problems that accompany the experience of sexual violence (e.g. sexual health/primary care clinics). Participants randomised were 99% women (3965 participants) with just 27 men. Half were Black, African or African-American (1889 participants); 40% White/Caucasian (1530 participants); and 10% represented a range of other ethnic backgrounds (396 participants). The weighted mean age was 35.9 years (standard deviation (SD) 9.6). Eighty-two per cent had experienced rape or sexual assault in adulthood (3260/3992). Twenty-two studies (61%) required fulfilling a measured PTSD diagnostic threshold for inclusion; however, 94% of participants (2239/2370) were reported as having clinically relevant PTSD symptoms at entry. The comparison of psychosocial interventions with inactive controls detected that there may be a beneficial effect at post-treatment favouring psychosocial interventions in reducing PTSD (standardised mean difference (SMD) -0.83, 95% confidence interval (CI) -1.22 to -0.44; 16 studies, 1130 participants; low-certainty evidence; large effect size based on Cohen's D); and depression (SMD -0.82, 95% CI -1.17 to -0.48; 12 studies, 901 participants; low-certainty evidence; large effect size). Psychosocial interventions, however, may not increase the risk of dropout from treatment compared to controls, with a risk ratio of 0.85 (95% CI 0.51 to 1.44; 5 studies, 242 participants; low-certainty evidence). Seven of the 23 studies (with 801 participants) comparing a psychosocial intervention to an inactive control reported on adverse events, with 21 events indicated. Psychosocial interventions may not increase the risk of adverse events compared to controls, with a risk ratio of 1.92 (95% CI 0.30 to 12.41; 6 studies; 622 participants; very low-certainty evidence). We conducted an assessment of risk of bias using the RoB 2 tool on a total of 49 reported results. A high risk of bias affected 43% of PTSD results; 59% for depression symptoms; 40% for treatment dropout; and one-third for adverse events. The greatest sources of bias were problems with randomisation and missing outcome data. Heterogeneity was also high, ranging from I2 = 30% (adverse events) to I2 = 87% (PTSD). AUTHORS' CONCLUSIONS: Our review suggests that survivors of rape, sexual violence and sexual abuse during adulthood may experience a large reduction in post-treatment PTSD symptoms and depressive symptoms after experiencing a psychosocial intervention, relative to comparison groups. Psychosocial interventions do not seem to increase dropout from treatment or adverse events/effects compared to controls. However, the number of dropouts and study attrition were generally high, potentially missing harms of exposure to interventions and/or research participation. Also, the differential effects of specific intervention types needs further investigation. We conclude that a range of behavioural and CBT-based interventions may improve the mental health of survivors of rape, sexual assault and sexual abuse in the short term. Therefore, the needs and preferences of individuals must be considered in selecting suitable approaches to therapy and support. The primary outcome in this review focused on the post-treatment period and the question about whether benefits are sustained over time persists. However, attaining such evidence from studies that lack an active comparison may be impractical and even unethical. Thus, we suggest that studies undertake head-to-head comparisons of different intervention types; in particular, of novel, emerging therapies, with one-year plus follow-up periods. Additionally, researchers should focus on the therapeutic benefits and costs for subpopulations such as male survivors and those living with complex PTSD.

A survey and stakeholder consultation of Independent Domestic Violence Advisor (IDVA) programmes in English maternity services.

BACKGROUND: Healthcare-based Independent Domestic Violence Advisors (hIDVA) are evidence-based programmes that provide emotional and practical support to service users experiencing domestic abuse. hIDVA programmes are found to improve health outcomes for service users and are increasingly delivered across a range of healthcare settings. However, it is unclear how hIDVA programmes are implemented across maternity services and the key facilitators and barriers to their implementation. The aim of this study was to identify; how many English National Health Service (NHS) Trusts with maternity services have a hIDVA programme; which departments within the Trust they operate in; what format, content, and variation in hIDVA programmes exist; and key facilitators and barriers of implementation in maternity services. METHODS: A national survey of safeguarding midwives (Midwives whose role specifically tasks them to protect pregnant women from harm including physical, emotional, sexual and financial harm and neglect) within all maternity services across England; descriptive statistics were used to summarise responses. A World Café event (a participatory method, which aims to create a café atmosphere to facilitate informal conversation) with 38 national key stakeholders to examine barriers and facilitators to hIDVA programme implementation. RESULTS: 86/124 Trusts (69%) with a maternity service responded to the survey; 59(69%) of respondents reported that they had a hIDVA programme, and 47(55%) of the hIDVA programmes operated within maternity services. Key facilitators to implementation of hIDVA programmes included training of NHS staff about the hIDVA role and regular communication between Trust staff and hIDVA staff; hIDVA staff working directly from the Trust; co-creation of hIDVA programmes with experts by experience; governance and middle- and senior-management support. Key barriers included hIDVA staff having a lack of access to a private space for their work, insecure funding for hIDVA programmes and issues with recruitment and retention of hIDVA staff. CONCLUSIONS: Despite hIDVA programmes role in improving the health outcomes of service users experiencing domestic abuse, increased funding and staff training is needed to successfully implement hIDVA staff in maternity services. Integrated Care Board commissioning of acute and mental health trust services would benefit from ensuring hIDVA programmes and clinician DVA training are prioritised.

Barriers and facilitators to pharmacists' engagement in response to domestic violence: a qualitative interview study informed by the capability-opportunity-motivation-behaviour model.

BACKGROUND: Domestic and sexual violence and abuse (DSVA) is a global public health problem resulting in health inequalities. Community pharmacies are uniquely placed to help people affected by DSVA. We examined factors that impact pharmacists' engagement in response to DSVA when providing public health services. METHODS: Semi-structured qualitative interviews with community pharmacists (n = 20) were analyzed thematically, with inductive themes mapped to the Capability-Opportunity-Motivation Behaviour (COM-B) model. RESULTS: Pharmacists were confident in providing public health services, but a lack of DSVA training meant there is a need to support their 'Capability' to respond to DSVA. Pharmacies were perceived as highly accessible healthcare providers on the high street, with sexual health consultations offering an ideal 'Opportunity' to enquire about DSVA in a private consultation room. Pharmacist's 'Motivation' to enquire about DSVA was driven by potential positive client outcomes and a desire to be more involved in public heath interventions, but organisation- and system-level support and remuneration is needed. CONCLUSIONS: Community pharmacy offers opportunities for integrating DSVA work in existing public health services. Pharmacists need training on DSVA, ongoing support, allocated funding for DSVA work, and awareness raising campaign for the public on their extended public health role.

Trauma-informed co-production: Collaborating and combining expertise to improve access to primary care with women with complex needs.

INTRODUCTION: Health, social care, charitable and justice sectors are increasingly recognising the need for trauma-informed services that seek to recognise signs of trauma, provide appropriate paths to recovery and ensure that services enable people rather than retraumatise. Foundational to the development of trauma-informed services is collaboration with people with lived experience of trauma. Co-production principles may provide a useful framework for this collaboration, due to their emphasis on lived experience, and intent to address power imbalances and promote equity. This article aims to examine trauma-informed and co-production principles to consider the extent to which they overlap and explore how to tailor co-production approaches to support people who have experienced trauma. METHODS: Bridging Gaps is a collaboration between women who have experienced complex trauma, a charity that supports them, primary care clinicians and health researchers to improve access to trauma-informed primary care. Using co-production principles, we aimed to ensure that women who have experienced trauma were key decision-makers throughout the project. Through reflective notes (n = 19), observations of meetings (n = 3), interviews with people involved in the project (n = 9) and reflective group discussions on our experiences, we share learning, successes and failures. Data analysis followed a framework approach, using trauma-informed principles. RESULTS: Co-production processes can require adaptation when working with people who have experienced trauma. We emphasise the need for close partnership working, flexibility and transparency around power dynamics, paying particular attention to aspects of power that are less readily visible. Sharing experiences can retrigger trauma. People conducting co-production work need to understand trauma and how this may impact upon an individual's sense of psychological safety. Long-term funding is vital to enable projects to have enough time for the establishment of trust and delivery of tangible results. CONCLUSIONS: Co-production principles are highly suitable when developing trauma-informed services. Greater consideration needs to be given as to whether and how people share lived experiences, the need for safe spaces, honesty and humility, difficult dynamics between empowerment and safety and whether and when blurring boundaries may be helpful. Our findings have applicability to policy-making, funding and service provision to enable co-production processes to become more trauma-informed. PUBLIC CONTRIBUTION: Bridging Gaps was started by a group of women who have experienced complex trauma, including addiction, homelessness, mental health problems, sexual exploitation, domestic and sexual violence and poverty, with a general practitioner (GP) who provides healthcare to this population, alongside a support worker from the charity One25, a charity that supports some of the most marginalised women in Bristol to heal and thrive. More GPs and healthcare researchers joined the group and they have been meeting fortnightly for a period of 4 years with the aim of improving access to trauma-informed primary care. The group uses co-production principles to work together, and we aim to ensure that women who have experienced trauma are key decision-makers throughout our work together. This article is a summary of our learning, informed by discussion, observations and interviews with members of the group.

Protocol for a randomised controlled trial of a healthy relationship tool for men who use intimate partner violence (BETTER MAN).

BACKGROUND: Intimate partner violence (IPV) is common globally, but there is a lack of research on how to intervene early with men who might be using IPV. Building on evidence supporting the benefits of online interventions for women victim/survivors, this study aims to test whether a healthy relationship website (BETTER MAN) is effective at improving men's help seeking, their recognition of behaviours as IPV and their readiness to change their behaviours. METHODS/DESIGN: In this two-group, pragmatic randomised controlled trial, men aged 18-50 years residing in Australia who have been in an adult intimate relationship (female, male or non-binary partner) in the past 12 months are eligible. Men who report being worried about their behaviour or have had others express concerns about their behaviour towards a partner in the past 12 months will be randomised with a 1:1 allocation ratio to receive the BETTER MAN website or a comparator website (basic healthy relationships information). The BETTER MAN intervention includes self-directed, interactive reflection activities spread across three modules: Better Relationships, Better Values and Better Communication, with a final "action plan" of strategies and resources. Using an intention to treat approach, the primary analysis will estimate between-group difference in the proportion of men who report undertaking help-seeking behaviours for relationship issues in the last 6 months, at 6 months post-baseline. Analysis of secondary outcomes will estimate between-group differences in: (i) mean score of awareness of behaviours in relationships as abusive immediately post-use of website; (ii) mean score on readiness to change immediately post-use of website and 3 months after baseline; and (iii) cost-effectiveness. DISCUSSION: This trial will evaluate the effectiveness of an online healthy relationship tool for men who may use IPV. BETTER MAN could be incorporated into practice in community and health settings, providing an evidence-informed website to assist men to seek help to promote healthy relationships and reduce use of IPV. TRIAL REGISTRATION: ACTRN12622000786796 with the Australian New Zealand Clinical Trials Registry: 2 June 2022. Version: 1 (28 September 2023).

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.

Exploring the causal role of intimate partner violence and abuse on depressive symptoms in young adults: a population-based cohort study.

BACKGROUND: Previous studies have shown an association between experience of intimate partner violence and abuse (IPVA) and depression. Whether this is a causal relationship or explained by prior vulnerability that influences the risk of both IPVA and depression is not known. METHODS: We analysed data from the Avon Longitudinal Study of Parents and Children prospective cohort (N = 1764 women, 1028 men). To assess the causal association between IPVA at 18-21 years old and logged depressive symptom scores at age 23, we used (i) multivariable linear regression, (ii) inverse probability of treatment weighting (IPTW), and (iii) difference-in-difference (DiD) analysis, which compared the mean change in logged depressive symptom scores between ages 16 and 23 between those who experienced IPVA and those who did not. RESULTS: Women who experienced IPVA had on average 26% higher depressive symptom scores after adjustment for measured confounders (ratio of geometric means 1.26, 95% CI 1.13 to 1.40). In men, the difference was 5% (ratio of geometric means 1.05, 95% CI 0.92 to 1.21). Results from IPTW analysis were similar. In the DiD analysis, there was no evidence that being exposed to IPVA affected the change in depressive symptom scores over time compared to being in the non-exposed group for either women (difference-in-differences 1%, -12 to 16%) or men (-1%, -19 to 20%). CONCLUSIONS: Multivariable linear regression and IPTW suggested an association between IPVA and higher depressive symptom score in women but not men, but DiD analysis indicated a null effect in both women and men. This suggests the causal origins of higher depressive symptoms in this young adult population are likely to reflect prior vulnerability that leads to both higher depressive symptoms and increased risk of IPVA exposure.

Domestic violence and self-poisoning in Sri Lanka.

BACKGROUND: There is increasing evidence that domestic violence (DV) is an important risk factor for suicidal behaviour. The level of risk and its contribution to the overall burden of suicidal behaviour among men and women has not been quantified in South Asia. We carried out a large case-control study to examine the association between DV and self-poisoning in Sri Lanka. METHODS: Cases (N = 291) were patients aged ⩾18 years, admitted to a tertiary hospital in Kandy Sri Lanka for self-poisoning. Sex and age frequency matched controls were recruited from the hospital's outpatient department (N = 490) and local population (N = 450). Exposure to DV was collected through the Humiliation, Afraid, Rape, Kick questionnaire. Multivariable logistic regression models were conducted to estimate the association between DV and self-poisoning, and population attributable fractions were calculated. RESULTS: Exposure to at least one type of DV within the previous 12 months was strongly associated with self-poisoning for women [adjusted OR (AOR) 4.08, 95% CI 1.60-4.78] and men (AOR 2.52, 95% CI 1.51-4.21), compared to those reporting no abuse. Among women, the association was strongest for physical violence (AOR 14.07, 95% CI 5.87-33.72), whereas among men, emotional abuse showed the highest risk (AOR 2.75, 95% CI 1.57-4.82). PAF% for exposure to at least one type of DV was 38% (95% CI 32-43) in women and 22% (95% CI 14-29) in men. CONCLUSIONS: Multi-sectoral interventions to address DV including enhanced identification in health care settings, community-based strategies, and integration of DV support and psychological services may substantially reduce suicidal behaviour in Sri Lanka.

Survivor, family and professional experiences of psychosocial interventions for sexual abuse and violence: a qualitative evidence synthesis.

BACKGROUND: It is well-established that experiencing sexual abuse and violence can have a range of detrimental impacts; a wide variety of interventions exist to support survivors in the aftermath. Understanding the experiences and perspectives of survivors receiving such interventions, along with those of their family members, and the professionals who deliver them is important for informing decision making as to what to offer survivors, for developing new interventions, and enhancing their acceptability. OBJECTIVES: This review sought to: 1. identify, appraise and synthesise qualitative studies exploring the experiences of child and adult survivors of sexual abuse and violence, and their caregivers, regarding psychosocial interventions aimed at supporting survivors and preventing negative health outcomes in terms of benefits, risks/harms and barriers; 2. identify, appraise and synthesise qualitative studies exploring the experiences of professionals who deliver psychosocial interventions for sexual abuse and violence in terms of perceived benefits, risks/harms and barriers for survivors and their families/caregivers; 3. develop a conceptual understanding of how different factors influence uptake, dropout or completion, and outcomes from psychosocial interventions for sexual abuse and violence; 4. develop a conceptual understanding of how features and types of interventions responded to the needs of different user/survivor groups (e.g. age groups; types of abuse exposure; migrant populations) and contexts (healthcare/therapeutic settings; low- and middle-income countries (LMICs)); 5. explore how the findings of this review can enhance our understanding of the findings from the linked and related reviews assessing the effectiveness of interventions aimed at supporting survivors and preventing negative health outcomes. SEARCH METHODS: In August 2021 we searched MEDLINE, Embase, PsycINFO and nine other databases. We also searched for unpublished reports and qualitative reports of quantitative studies in a linked systematic review, together with reference checking, citation searches and contacting authors and other researchers to identify relevant studies. SELECTION CRITERIA: We included qualitative and mixed-methods studies (with an identifiable qualitative component) that were linked to a psychosocial intervention aimed at supporting survivors of sexual abuse and violence. Eligible studies focused on at least one of three participant groups: survivors of any age, gender, sexuality, ethnicity or [dis]ability who had received a psychosocial intervention; their carers, family members or partners; and professionals delivering such interventions. We placed no restrictions in respect of settings, locations, intervention delivery formats or durations. DATA COLLECTION AND ANALYSIS: Six review authors independently assessed the titles, abstracts and full texts identified. We extracted data using a form designed for this synthesis, then used this information and an appraisal of data richness and quality in order to stratify the studies using a maximum variation approach. We assessed the methodological limitations using the Critical Skills Appraisal Programme (CASP) tool. We coded directly onto the sampled papers using NVivo and synthesised data using a thematic synthesis methodology and used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We used a narrative synthesis and matrix model to integrate our qualitative evidence synthesis (QES) findings with those of intervention review findings. MAIN RESULTS: We identified 97 eligible studies and sampled 37 of them for our analysis. Most sampled studies were from high-income countries, with four from middle-income and two from low-income countries. In 27 sampled studies, the participants were survivors, in three they were intervention facilitators. Two included all three of our stakeholder groups, and five included two of our groups. The studies explored a wide range of psychosocial interventions, with only one type of intervention explored in more than one study. The review indicates that features associated with the context in which interventions were delivered had an impact on how individuals accessed and experienced interventions. This included organisational features, such as staff turnover, that could influence survivors' engagement with interventions; the setting or location in which interventions were delivered; and the characteristics associated with who delivered the interventions. Studies that assess the effectiveness of interventions typically assess their impact on mental health; however, as well as finding benefits to mental health, our QES found that study participants felt interventions also had positive impacts on their physical health, mood, understanding of trauma, interpersonal relationships and enabled them to re-engage with a wide range of areas in their lives. Participants explained that features of interventions and their contexts that best enabled them to benefit from interventions were also often things that could be a barrier to benefiting from interventions. For example, the relationship with the therapist, when open and warm was a benefit, but if such a relationship could not be achieved, it was a barrier. Survivors' levels of readiness and preparedness to both start and end interventions could have positive (if they were ready) or negative (if they were not) impacts. Study participants identified the potential risks and harms associated with completing interventions but felt that it was important to face and process trauma. Some elements of interventions were specific to the intervention type (e.g. faith-based interventions), or related to an experience of an intervention that held particular relevance to subgroups of survivors (e.g. minority groups); these issues could impact how individuals experienced delivering or receiving interventions. AUTHORS' CONCLUSIONS: We had high or moderate confidence in all but one of our review findings. Further research in low- and middle-income settings, with male survivors of sexual abuse and violence and those from minority groups could strengthen the evidence for low and moderate confidence findings. We found that few interventions had published quantitative and qualitative evaluations. Since this QES has highlighted important aspects that could enable interventions to be more suitable for survivors, using a range of methodologies would provide valuable information that could enhance intervention uptake, completion and effectiveness. This study has shown that although survivors often found interventions difficult, they also appreciated that they needed to work through trauma, which they said resulted in a wide range of benefits. Therefore, listening to survivors and providing appropriate interventions, at the right time for them, can make a significant difference to their health and well-being.

Domestic violence and injuries: prevalence and patterns-a pilot database study to identify suspected cases in a UK major trauma centre.

BACKGROUND: Victim-survivors of domestic violence and abuse (DVA) present to secondary care with isolated injuries to the head, limb or face. In the UK, there are no published studies looking at the relationship of significant traumatic injuries in adults and the relationship to DVA.The primary objective was to assess the feasibility of using a tailored search method to identify cases of suspected DVA in the national audit database for trauma. The secondary objective was to assess the association of DVA with clinical characteristics. METHODS: We undertook a single-centre retrospective observational cohort pilot study. Data were analysed from the local Trauma and Audit Research Network (TARN) database. The 'Scene Description' field in the database was searched using a tailored search strategy. Feasibility was evaluated with notes review and assessed by the PPV and prevalence. Secondary objectives used a logistic regression in Excel. RESULTS: This method of identifying suspected cases of DVA from the TARN database is feasible. The PPV was 100%, and the prevalence of suspected DVA in the study period was 3.6 per 1000 trauma discharges. Of those who had experienced DVA, 52.7% were male, median age 43 (IQR: 33-52) and mortality 5.5%. Subgroup analysis of older people demonstrated longer hospital stay (p=0.17) and greater likelihood of admission to intensive care (OR 2.60, 95% CI 0.48 to 14.24). CONCLUSION: We have created a feasible methodology to identify suspected DVA-related injuries within the TARN database. Future work is needed to further understand this relationship on a national level.

Being silenced, loneliness and being heard: understanding pathways to intimate partner violence & abuse in young adults. a mixed-methods study.

BACKGROUND: International research shows the significance and impact of intimate partner violence and abuse (IPVA) as a public health issue for young adults. There is a lack of qualitative research exploring pathways to IPVA. METHODS: The current mixed-methods study used qualitative interviews and analysis of longitudinal cohort data, to explore experiences of pathways to IPVA. Semi-structured Interviews alongside Life History Calendars were undertaken to explore 17 young women's (19-25 years) experiences and perceptions of pathways to IPVA in their relationships. Thematic analysis was undertaken. Based on themes identified in the qualitative analysis, quantitative analysis was conducted in data from 2127 female and 1145 male participants of the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort study. We fitted regression models to assess the association of child maltreatment, parental domestic violence, and peer-to-peer victimisation, by age 12, with loneliness during adolescence (ages 13-14), and the association of loneliness during adolescence with IPVA (age 18-21). Mediation analysis estimated the direct effects of maltreatment on IPVA, and indirect effects through loneliness. FINDINGS: All women interviewed experienced at least one type of maltreatment, parental domestic violence, or bullying during childhood. Nearly all experienced IPVA and most had been multi-victimised. Findings indicated a circular pathway: early trauma led to isolation and loneliness, negative labelling and being silenced through negative responses to help seeking, leading to increased experiences of loneliness and intensifying vulnerability to further violence and abuse in young adulthood. The pathway was compounded by intersectionality. Potential ways to break this cycle of loneliness included being heard and supported, especially by teachers. Quantitative analysis confirmed an association between child maltreatment and loneliness in adolescence, and an association between loneliness in adolescence and experience of IPVA in young adult relationships. CONCLUSION: It is likely that negative labelling and loneliness mediate pathways to IPVA, especially among more disadvantaged young women. The impact of early maltreatment on young people's wellbeing and own relationships is compounded by disadvantage, disability and ethnicity. Participants' resilience was enabled by support in the community.

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.

Access to healthcare for street sex workers in the UK: perspectives and best practice guidance from a national cross-sectional survey of frontline workers.

BACKGROUND: Street sex workers (SSWs) are a highly marginalised and stigmatised group who carry an extremely high burden of unmet health need. They experience multiple and interdependent health and social problems and extreme health inequality. Despite high levels of chronic physical and mental ill-health, there is little evidence of effective healthcare provision for this group. They are often considered 'hard to reach', but many individuals and organisations have extensive experience of working with this group. METHODS: We conducted a cross-sectional survey of professionals who work with SSWs in the UK on their perspectives on their access to primary care, mental health, sexual health and drug and alcohol services, how well these services met the needs of SSWs and suggestions of best practice. RESULTS: 50 professionals mostly from England, responded. Mainstream general practice and mental health services were found to be largely inaccessible to SSWs. Sexual health, drug and alcohol services and homeless health services better met their needs; this was mostly attributed to flexible services and collaborations with organisations who work closely with SSWs. The main challenges in providing healthcare to SSWs were services being inflexible, under-resourced services and services not being trauma-informed. Best practice in providing healthcare to SSWs includes- seamless partnership working between agencies with case worker support; peer-involvement in service development and engagement, a range of health provision including outreach, presence in community spaces and fast-track access into mainstream services; trauma-informed, gender-sensitive health services in a welcoming environment with flexible, responsive appointment and drop-in systems and consistent clinicians with specialist knowledge of substance misuse, mental health, domestic violence and homelessness. CONCLUSIONS: Access to healthcare for SSWs in the UK is highly variable but largely inadequate with regards to primary care and mental health provision. The examples of positive healthcare provision and partnership working presented here demonstrate the feasibility of accessible healthcare that meets the needs of SSWs. These need to be systematically implemented and evaluated to understand their impact and implications. As we build back from COVID-19 there is an urgent need to make accessible healthcare provision for marginalised groups the norm, not the exception.

Improving health system readiness to address violence against women and girls: a conceptual framework.

BACKGROUND: There is an increasing focus on readiness of health systems to respond to survivors of violence against women (VAW), a global human rights violation damaging women's health. Health system readiness focuses on how prepared healthcare systems and institutions, including providers and potential users, are to adopt changes brought about by the integration of VAW care into services. In VAW research, such assessment is often limited to individual provider readiness or facility-level factors that need to be strengthened, with less attention to health system dimensions. The paper presents a framework for health system readiness assessment to improve quality of care for intimate partner violence (IPV), which was tested in Brazil and Palestinian territories (oPT). METHODS: Data synthesis of primary data from 43 qualitative interviews with healthcare providers and health managers in Brazil and oPT to explore readiness in health systems. RESULTS: The application of the framework showed that it had significant added value in capturing system capabilities - beyond the availability of material and technical capacity - to encompass stakeholder values, confidence, motivation and connection with clients and communities. Our analysis highlighted two missing elements within the initial framework: client and community engagement and gender equality issues. Subsequently, the framework was finalised and organised around three levels of analysis: macro, meso and micro. The micro level highlighted the need to also consider how the system can sustainably involve and interact with clients (women) and communities to ensure and promote readiness for integrating (and participating in) change. Addressing cultural and gender norms around IPV and enhancing support and commitment from health managers was also shown to be necessary for a health system environment that enables the integration of IPV care. CONCLUSION: The proposed framework helps identify a) system capabilities and pre-conditions for system readiness; b) system changes required for delivering quality care for IPV; and c) connections between and across system levels and capabilities.

Domestic abuse education in UK GP training schemes: cross-sectional study.

BACKGROUND: Domestic abuse (DA) is a violation of human rights that damages physical and mental health. Healthcare services is the most common agency a woman experiencing DA may present to. DA is part of the GP postgraduate training curriculum in the UK, but we do not know how this is being implemented in registrar training. AIM: To investigate the implementation of domestic abuse education in GP training schools across the UK. DESIGN AND SETTING: Cross-sectional survey of UK postgraduate GP training groups. METHOD: Digital surveys were emailed to all UK postgraduate GP training groups. The survey contained quantitative and free-text questions about descriptive features of education provided and self-reported perceptions. The survey was sampled by programme directors (PDs) and trainees. Data was collected and analysed descriptively. RESULTS: Seventy of the 115 (52%) GP postgraduate training groups responded. 44.2% of the groups did not offer DA education. If available, DA education sessions had different lengths of teaching, facilitators, content and methods. When asked if training was adequate, 47.4% of trainees disagreed and 36.8% strongly disagreed. Throughout the questions, PDs ranked the quality of education higher than trainees. PD's reasons for not providing DA education included lack of time and resources, but also cultural perceptions of DA being a taboo subject and not clinical. CONCLUSION: Our survey shows that the provision of DA education in UK postgraduate GP training is absent in almost half the programmes and varies in length, content and quality, with a high proportion of respondents rating it inadequate.

Shared decision making in consultations for hypertension: Qualitative study in general practice.

BACKGROUND: Hypertension is mainly managed in primary care. Shared decision making is widely recommended as an approach to treatment decision making. However, no studies have investigated; in detail, what happens during primary care consultations for hypertension. AIM: To understand patients' and clinicians' experience of shared decision making for hypertension in primary care, in order to propose how it might be better supported. DESIGN: Longitudinal qualitative study. SETTING: Five general practices in south-west England. METHOD: Interviews with a purposive sample of patients with hypertension, and with the health-care practitioners they consulted, along with observations of clinical consultations, for up to 6 appointments. Interviews and consultations were audio-recorded and observational field notes taken. Data were analysed thematically. RESULTS: Forty-six interviews and 18 consultations were observed, with 11 patients and nine health-care practitioners (five GPs, one pharmacist and three nurses). Little shared decision making was described by participants or observed. Often patients' understanding of their hypertension was limited, and they were not aware there were treatment choices. Consultations provided few opportunities for patients and clinicians to reach a shared understanding of their treatment choices. Opportunities for patients to engage in choices were limited by structured consultations and the distribution of decisions across consultations. CONCLUSION: For shared decision making to be better supported, consultations need to provide opportunities for patients to learn about their condition, to understand that there are treatment choices, and to discuss these choices with clinicians. PATIENT OR PUBLIC CONTRIBUTION: A patient group contributed to the design of this study.

ADVANCE integrated group intervention to address both substance use and intimate partner abuse perpetration by men in substance use treatment: a feasibility randomised controlled trial.

BACKGROUND: Substance use is a risk factor for intimate partner abuse (IPA) perpetration. Delivering perpetrator interventions concurrently with substance use treatment shows promise. METHODS: The feasibility of conducting an efficacy and cost-effectiveness trial of the ADVANCE 16-week intervention to reduce IPA by men in substance use treatment was explored. A multicentre, parallel group individually randomised controlled feasibility trial and formative evaluation was conducted. Over three temporal cycles, 104 men who had perpetrated IPA towards a female (ex) partner in the past year were randomly allocated to receive the ADVANCE intervention + substance use treatment as usual (TAU) (n = 54) or TAU only (n = 50) and assessed 16-weeks post-randomisation. Participants' (ex) partners were offered support and 27 provided outcome data. Thirty-one staff and 12 men who attended the intervention participated in focus groups or interviews that were analysed using the framework approach. Pre-specified criteria assessed the feasibility of progression to a definitive trial: 1) ≥ 60% of eligible male participants recruited; 2) intervention acceptable to staff and male participants; 3) ≥ 70% of participants followed-up and 4) levels of substance use and 5) IPA perpetrated by men in the intervention arm did not increase from average baseline level at 16-weeks post-randomisation. RESULTS: 70.7% (104/147) of eligible men were recruited. The formative evaluation confirmed the intervention's acceptability. Therapeutic alliance and session satisfaction were rated highly. The overall median rate of intervention session attendance (of 14 compulsory sessions) was 28.6% (range 14.3-64.3% by the third cycle). 49.0% (51/104) of men and 63.0% (17/27) of their (ex) partners were followed-up 16-weeks post-randomisation. This increased to 100% of men and women by cycle three. At follow-up, neither substance use nor IPA perpetration had worsened for men in the intervention arm. CONCLUSIONS: It was feasible to deliver the ADVANCE intervention in substance use treatment services, although it proved difficult to collect data from female (ex)partners. While some progression criteria were met, others were not, although improvements were demonstrated by the third cycle. Lessons learned will be implemented into the study design for a definitive trial of the ADVANCE intervention. TRIAL REGISTRATION: ISRCTN79435190 prospectively registered 22nd May 2018.

Reaching everyone in general practice? Feasibility of an integrated domestic violence training and support intervention in primary care.

BACKGROUND: Primary care needs to respond effectively to patients experiencing or perpetrating domestic violence and abuse (DVA) and their children, but there is uncertainty about the value of integrated programmes. The aim of the study was to develop and test the feasibility of an integrated primary care system-level training and support intervention, called IRIS+ (Enhanced Identification and Referral to Improve Safety), for all patients affected by DVA. IRIS+ was an adaptation of the original IRIS (Identification and Referral to Improve Safety) model designed to reach female survivors of DVA. METHODS: Observation of training; pre/post intervention questionnaires with clinicians and patients; data extracted from medical records and DVA agency; semi-structured interviews with clinicians, service providers and referred adults and children. Data collection took place between May 2017 and April 2018. Mixed method analysis was undertaken to triangulate data from various sources to assess the feasibility and acceptability of the intervention. RESULTS: Clinicians and service providers believed that the IRIS+ intervention had filled a service gap and was a valuable resource in identifying and referring women, men and children affected by DVA. Despite increased levels of preparedness reported by clinicians after training in managing the complexity of DVA in their practice, the intervention proved to be insufficient to catalyse identification and specialist referral of men and direct identification and referral (without their non-abusive parents) of children and young people. The study also revealed that reports provided to general practice by other agencies are important sources of information about adult and children patients affected by DVA. However, in the absence of guidance about how to use this information in patient care, there are uncertainties and variation in practice. CONCLUSIONS: The study demonstrates that the IRIS+ intervention is not feasible in the form and timeframe we evaluated. Further adaptation is required to achieve identification and referral of men and children in primary care: an enhanced focus on engagement with men, direct engagement with children, and improved guidance and training on responding to reports of DVA received from other agencies.

Adaptive work in the primary health care response to domestic violence in occupied Palestinian territory: a qualitative evaluation using Extended Normalisation Process Theory.

BACKGROUND: A health system response to domestic violence against women is a global priority. However, little is known about how these health system interventions work in low-and-middle-income countries where there are greater structural barriers. Studies have failed to explore how context-intervention interactions affect implementation processes. Healthcare Responding to Violence and Abuse aimed to strengthen the primary healthcare response to domestic violence in occupied Palestinian territory. We explored the adaptive work that participants engaged in to negotiate contextual constraints. METHODS: The qualitative study involved 18 participants at two primary health care clinics and included five women patients, seven primary health care providers, two clinic case managers, two Ministry of Health based gender-based violence focal points and two domestic violence trainers. Semi-structured interviews were used to elicit participants' experiences of engaging with HERA, challenges encountered and how these were negotiated. Data were analysed using thematic analysis drawing on Extended Normalisation Process Theory. We collected clinic data on identification and referral of domestic violence cases and training attendance. RESULTS: HERA interacted with political, sociocultural and economic aspects of the context in Palestine. The political occupation restricted women's movement and access to support services, whilst the concomitant lack of police protection left providers and women feeling exposed to acts of family retaliation. This was interwoven with cultural values that influenced participants' choices as they negotiated normative structures that reinforce violence against women. Participants engaged in adaptive work to negotiate these challenges and ensure that implementation was safe and workable. Narratives highlight the use of subterfuge, hidden forms of agency, governing behaviours, controls over knowledge and discretionary actions. The care pathway did not work as anticipated, as most women chose not to access external support. An emergent feature of the intervention was the ability of the clinic case managers to improvise their role. CONCLUSIONS: Flexible use of ENPT helped to surface practices the providers and women patients engaged in to make HERA workable. The findings have implications for the transferability of evidenced based interventions on health system response to violence against women in diverse contexts, and how HERA can be sustained in the long-term.