Author: Litherland, Rachel
Date published: August 1, 2012
Journal code: CPRA
Although many definitions exist, the World Health Organization (WHO) (2010) definition of domestic abuse portrays the entire spectrum of abuse, by describing it as physical attacks, sexual coercion and psychological control within an intimate relationship. Research indicates that domestic abuse causes:
* Poor physical, sexual and psychological health for victims
* Compromised parenting
* Physical injuries to the victims' children, as well as behavioural, educational and psychological problems
* A total cost to the UK economy of £23billion per annum, broken down into healthcare costs, police resources, court fees and time lost at work (Department of Health (DH), 2010).
Nationally, there are over one million reported female victims, amounting to one in four women (HM Government, 2010). Disclosure of abuse is recognised as being a significant step in breaking isolation and providing access to further support (Feder et al, 2009; Spangaro et al, 2010). Health visitors are known to play a lead role; as a statutory obligation they are required to prevent and identify domestic abuse (Nursing and Midwifery Council (NMC), 2004). Additionally, as over one-third of cases begin during pregnancy and then escalate postnatally (DH, 2010), health visitors are ideally placed to identify those women experiencing abuse, as their role commences during the antenatal period and they offer universal support to all postnatal women. The aim of this paper is to review the evidence and determine strategies that will more effectively identify abuse, ultimately aiming to reduce maternal and child morbidity when implemented within practice.
It is acknowledged that men can be victims of domestic abuse as well as women, and that abuse occurs within same-sex relationships (Hester et al, 2007). However, as the incidence of domestic abuse occurs disproportionately against females by males (DH, 2005), this paper will centre upon abuse against women by men. Furthermore, while support for domestic abuse victims is paramount, this is not the focal point of the paper.
This paper takes the form of a library-based literature review conducted during August 2011. The methodology recommended by Burns and Grove (2001) was used.
Initially, a brief search was conducted using the online database CINAHL. This enabled understanding of the basic concepts and theories. From here, a more extensive search of online databases occurred, focusing upon keywords and synonyms of the paper's title. So that literature could be thoroughly analysed, searches were limited to full-text articles. Furthermore, the search was limited to articles published in the previous ten years. Table 1 shows the findings.
Online searches and hand searches of professional journals were carried out. The search concluded when reccurring patterns, authors and articles emerged. The search strategy located 58 potential papers in total. Each paper's abstract and summary was read to determine its relevance. From here, more comprehensive reading occurred with articles eliminated if deemed irrelevant. Although preference was given to UK studies, due to only nine papers retrieved from this origin, papers were also included from the 'developed world' (particularly the USA, Canada and Australia). Although inclusion of studies from outside the UK may impede transferability, the author will comment, where appropriate, upon a study's sampling methods to determine whether findings are applicable to the UK.
The final volume of papers for review was 18. Each paper was critically appraised to gain a balanced, objective view. This involved carefully assessing the strengths and weaknesses of the study design, methodology and findings to determine its overall credibility (Burns and Grove, 2001). During this process, a 'summary and concept map' (Burns and Grove, 2001) was produced to reveal similarities and inconsistencies in findings across different papers. This process also enabled similar concepts or guiding themes to emerge. Below follows a critical analysis of the literature in relation to these themes. However, the themes should not be considered in isolation since each is intrinsically linked to, and impacts upon, other themes.
Routine vs selective enquiry
Domestic abuse spans all socio-economic, ethnic, religious and age populations, and no particular group is considered more vulnerable (WHO, 2010). Organisations have attempted to categorise abuse indicators (including unexplained injuries, frequent A8cE attendances, anxiety) but there is now recognition that abuse is often concealed by victims, or is not immediately apparent - particularly non-physical forms (Roswell, 2003; DH, 2005). Consequently, the DH (2005) recommends 'routine enquiry', which, compared to 'selective enquiry', involves asking all women about domestic abuse, regardless of indicators. This is pertinent to health visitors as this is a proactive approach, in line with the principles of public health that frame practice. Routine enquiry also encourages non -discriminatory practice by not defining particular social groups as more 'vulnerable' (DH, 2005).
Literature overwhelmingly indicates that routine enquiry results in higher incidences of abuse disclosure (Janssen et al, 2002; Bacchus et al, 2003; Spangaro et al, 2010), highlighting that, unless asked, the majority of women do not disclose abuse voluntarily. Significantly, each of these studies originates from a different country (UK, USA and Canada), with me non-UK studies being large-scale and multi-setting in nature. Although every study is setting and time-specific, these factors increase the transferability of the findings to UK practice (Burns and Grove, 2001 ).
Better outcomes for women and children
Routine enquiry has been found to increase disclosure rates, but debate is lacking in the literature regarding any long-term benefits. Richardson et al (2002) report a deficit of such evidence. However, a large-scale randomised, controlled trial (RCT) has found that routine enquiry followed by disclosure and access to further information and support, was associated with significantly fewer threats and acts of abuse two years later, with subsequent improvements in maternal and child emotional and physical wellbeing (McFarlane et al, 2006). These findings are significant as this is a methodologically robust RCT - generally regarded as the most reliable form of empirical evidence (Burns and Grove, 2001). This adds weight to the value of routine enquiry in terms of improving health outcomes for women and children.
Price et al (2007) recognise that the key factor leading to improved outcomes following routine enquiry and abuse disclosure, is having clear referral pathways for support including voluntary agencies, MARAC conferences and local Independent Domestic Abuse Advisors (IDVAs). This indicates that it is not enough to simply ask about domestic abuse but, instead, that a number of agencies at various levels are required to enable women to feel supported, safe and make informed choices, and ultimately improve outcomes. This poses a dilemma, as access to local voluntary services for abuse victims is variable across the country (HM Government, 2010) and it is questionable whether it is ethical to routinely enquire about domestic abuse if support services are not easily accessible. However, it could be argued that support from national organisations such as Refuge and Women's Aid are available to all, and that by not routinely asking regarding domestic abuse, the true need for local support agencies will never be recognised and will remain insufficient.
Generally, research indicates that women find routine enquiry acceptable (Janssen et al, 2002; Chen et al, 2007). Bateman and Whitehead (2004) found that within a health visiting setting, women were 'grateful' to be asked about abuse. Conversely, Richardson et al (2002) report that 20% of their study participants objected to abuse enquiry. However, critical analysis of this paper may reveal implicit values. The way in which statistics are presented can impact upon how they are interpreted by readers; the researchers focus on the minority group rather than the 80% who found enquiry acceptable, perhaps indicating the researcher's underlying beliefs. Nevertheless, the study provides interesting debate. In light of the majority of evidence reviewed, routine enquiry appears in alignment with women's expressed needs. For health visitors who are concerned with identifying and satisfying the population's health needs, this is significant.
Domestic abuse screening tools take the enquiry process one step further. Screening tools standardise the enquiry approach (Feder et al, 2009) and it is this that sets 'screening' apart from 'enquiry'. Feder et al (2009) state domestic abuse 'screening' does not meet the UK National Screening Committee's criterion since domestic abuse is not a 'disease' requiring detection only in the early stages. However, Price et al (2007) remind us of our professional accountability to ensure families' welfare, and point out that whatever terminology is used, evidence indicates that women want to be asked about abuse and this cannot be ignored.
Furthermore, Bateman and Whitehead (2004) note the importance of professionals using a screening tool because, without a consistent approach, enquiry can be vague and generate uncertainty for women. Conversely, screening tools 'normalise' the process and result in higher incidences of disclosure (Hamberger and Phelan, 2006; O'Reilly et al, 2010).
The literature search identified a variety of domestic abuse screening tools, for example Webster et al (see Box 1 ). A significant strength of some screening tools is the presence of an opening statement that provides justification for screening in terms of prevalence and health impact of abuse. This demonstrates that the organisation undertaking screening takes the issue seriously (Hester et al, 2007). A further strength is those tools that encapsulate the entire spectrum of abuse. This is an important feature to accurately detect abuse and to enhance awareness amongst women of the various behaviours constituting abuse (Roswell, 2003). Undoubtedly, screening tools for domestic abuse need to be non-judgemental and sensitive to the needs of women, and effective in identifying the various forms of abuse.
Barriers to identification
Inadequate practitioner knowledge is a recognised barrier to domestic abuse identification (Rose et al, 201 1). A number of studies indicate a 'medical model' of care adopted by some professionals. Rhodes et al (2007) found that A&E staff treated only women's physical injuries, paying minimal regard to domestic abuse, even when suspected. Bateman and Whitehead (2004) found similar behaviours among UK GPs. This suggests perceptions that domestic abuse, as a social issue, is outside the medical domain (Rose et al, 2011). This model does little to support women's needs or aid abuse identification (Hamberger and Phelan, 2006). This is significant for health visitors who work collaboratively, particularly with GPs.
Peckover (2003a) found that two-thirds of health visitors in her study viewed domestic abuse solely within physical realms. This has practice implications in terms of minimising the extent of abuse (Peckover, 2003a). However, the study consisted of a small sample from the same trust. It is unlikely, therefore, that this narrow sample is representative of the national health visiting profession. This limits transferability of findings to other settings, but does indicate the need for local trusts to audit staff knowledge and implement training in response, and consider that me presence of a domestic abuse screening tool within client records, as part of a clinical pathway, would promote more effective abuse identification (DH, 2005).
Time pressures and work loads are documented barriers to identification (Hamberger and Phelan, 2006). Chen et al (2007) dispute this, arguing that enquiry and screening takes only a few minutes. However, most health visitors would assert that it is not asking the question that takes time, but dealing with disclosures. With reductions in health visitor numbers, this issue is undoubtedly pertinent. Health visitors may already feel overwhelmed, without the addition of another 'task'.
Rhodes et al (2007), in a qualitative analysis within an Emergency Department, found that the presence of a third-party member posed a barrier to women's disclosure of abuse. However, this study's ethics are seriously questionable as there is a general consensus that enquiry must occur privately, as a matter of safety for the client and practitioner (Bateman and Whitehead, 2004; DH, 2005). However, the very nature of the abusive partner may make it difficult to see women alone (DH, 2005). Bacchus et al's (2003) UK-based qualitative study also indicates that lack of privacy presents a barrier for women disclosing abuse, particularly within busy clinics. Applied to health visiting, this is a likely barrier particularly within 'Well Baby Clinics'. To counter this, literature advocates the use of appropriate posters or leaflets within clinical areas (eg, waiting rooms, bathrooms) (Bacchus et al, 2003; Hamberger and Phelan, 2006) that enable women to self-refer.
Psychological and sociological perspectives may also aid understanding of why some women conceal abuse. Roswell (2003) describes the 'myth of the perfect famil/, which can act as an oppressive force to disclosing abuse. Additionally, Wallace (2007) describes a psychological phenomenon known as 'Stockholm Syndrome' whereby women create strong emotional bonds with their abusers. Superficially, it may appear that women are minimising abuse, even colluding with their abuser (Hester et al, 2007). Deeper analysis, however, reveals a strategy for survival in terms of appeasing abusive partners and ultimately reducing abusive episodes (Wallace, 2007). This offers an interesting perspective for why women do not disclose abuse. It is important therefore for professionals to acknowledge the complex nature of abusive relationships and me strategies that women adopt to stay safe (Roswell, 2003).
Importance of 'trust' and information-giving
Analysis of the literature reveals that 'trust' is a key feature influencing disclosure. Literature identifies that women are frightened tliat disclosure may cause abuse escalation or result in children being removed (Rose et al, 2011). However, research reveals that women who trust their practitioners disclose abuse, regardless of fears (Bateman and Whitehead, 2004; Hamberger and Phelan, 2006). Bateman and Whitehead (2004) reveal that trust is associated with open communication, 'feeling heard', maintaining confidentiality (within professional limits) and having a caring disposition. They found that, generally, health visitors adopted this approach with women feelingthat this profession were lessjudgemental and more in tune with their needs. Thus, disclosure came more readily. However, for professionals such as health visitors, who have statutory obligations within the safeguarding arena, some women may be cautious to disclose abuse. Indeed, Peckover (2003b) found that women perceived health visitors as 'policing the family'; ultimately resulting in women's concealment of abuse. It is unclear why two studies of similar methodological design, both undertaken within Northern England, revealed such varied perspectives. Nevertheless, it is important that health visitors have awareness of the public's perspective and the subsequent impact upon disclosure.
Hester et al (2007) identify that trust is a concept that materialises over time. This supports literature indicating that recurrent enquiry/screening is necessary before disclosure occurs (Hamberger and Phelan, 2006; O'Reilly et al, 2010). Importantly, for several studies, routine screening occurred simultaneously with giving easily concealed, wallet-sized information cards to all women - regardless of whether they disclosed abuse - that provided key information on domestic abuse support services (Janssen et al, 2002; Spangaro et al, 2010). The DH (2005) recognises this as good practice. Moreover, this practice acknowledges those women who fail to disclose abuse - known as 'false negatives'. Significantly, Spangaro et al (2010) report that 81% of all study participants read or used the information card in some way, either for themselves or for a friend/family member. This indicates the value of information-giving to women.
The literature review highlighted that domestic abuse spans all sections of society, is largely hidden and not readily disclosed. Consequently, the majority of literature advocates routine enquiry for domestic abuse. Literature identifies that women favour this approach and that it has long-term benefits in terms of reducing threats and acts of abuse. The use of screening tools was also found to result in even higher disclosure rates. However, it was found that some women may continue to conceal abuse as part of their coping strategy. The literature review therefore advocated multiple assessments, information giving to all women following enquiry/screening, a caring disposition from practitioners, and clinical environments that promote self-referral.
Health visitors are recognised as being ideally placed to routinely enquire about domestic abuse due to their universal contact with women during the antenatal and postnatal period - a time when abuse is most likely to begin or escalate. While some research indicates the healtii visitor's holistic, non-judgemental approach facilitates disclosure of abuse, their statutory obligations within the child protection arena is a likely barrier and health visitors need to be aware of this.
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Rachel Litherland PGdip BSc RHV RM
Health Visitor, Bridgewater Community Healthcare (Ashton, Leigh and Wigan Division)
Correspondence to: Rachel.Litherland@bridgewater.nhs.uk