Health Care Response to Domestic Violence Essay

Health Care Response to Domestic Violence Essay

Domestic Violence:

A pattern of assaultive and coercive behaviors, including physical, sexual, and psychological attacks as well as economic coercion, that adults or adolescents use against their intimate partners.


Domestic violence is virtually impossible to measure with absolute precision due to numerous complications including the societal stigma that inhibits victims from disclosing their abuse and the varying definitions of abuse used from study to study. Estimates range from 960,000 incidents of violence against a current or former spouse, boyfriend, or girlfriend per year1 to 3.9 million women who are physically abused per year.2

On July 22, 1997, UNICEF released The Progress of Nations, 1997, which found that a quarter to half of women around the world have suffered violence from an intimate partner.3

Nearly one-third of American women (31 percent) report being physically or sexually abused by a husband or boyfriend at some point in their lives, according to a 1998 Commonwealth Fund survey.


Thirty percent of Americans say they know a woman who has been physically abused by her husband or boyfriend in the past year.5

While women are less likely than men to be victims of violence crimes overall, women are five to eight times more likely than men to be victimized by an intimate partner. Health Care Response to Domestic Violence Essay.

Injuries and Other Health Consequences of Domestic Violence:

The U.S. Department of Justice reported that 37% of all women who sought care in hospital emergency rooms for violence-related injuries were injured by a current or former spouse, boyfriend or girlfriend.7

Domestic violence is repetitive in nature: about 1 in 5 women victimized by their spouse or ex-spouse reported that they had been a victim of a series of at least 3 assaults in the last 6 months.

The level of injury resulting from domestic violence is severe: of 218 women presenting at a metropolitan emergency department with injuries due to domestic violence, 28% required hospital admission, and 13% required major medical treatment. 40% had previously required medical care for abuse.

In 1996, approximately, 1,800 murders were attributed to intimates; nearly three out of four of these had a female victim.10

Costs of Domestic Violence:

From 1987 to 1990, crime costs Americans $450 billion a year. Adult victims of domestic violence incurred 15% of the total cost of crime on victims ($67 billion).

A study conducted at Rush Medical Center in Chicago found that the average charge for medical services provided to abused women, children and older people was $1,633 per person per year. This would amount to a national annual cost of $857.3 million.

A study conducted at a large health plan in Minneapolis and St. Paul, Minnesota, in 1994, found that an annual difference of $1775.00 more was spent on abused women who utilized hospital services than on a random sample of general enrollees. The study concluded that early identification and treatment of victims and potential victims will most likely benefit health care systems in the long run.

Identification of Domestic Violence:

92% of women who were physically abused by their partners did not discuss these incidents with their physicians; 57% did not discuss the incidents with anyone.

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.


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.Health Care Response to Domestic Violence Essay.  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.


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.


This paper reports the protocol for a system wide implementation evaluation of IRIS – Identification and Referral to Improve Safety of women affected by domestic violence and abuse (DVA), a complex intervention, designed to improve the primary healthcare response to DVA.

According to World Health Organization (WHO) and National Institute for Health and Care Excellence (NICE) guidelines, health professionals should be trained to provide assistance for women affected by DVA by facilitating disclosure, checking their safety, offering support and referral, and providing the appropriate medical services and follow-up care [1, 2]. These guideline recommendations are based on research from multiple health settings. This research includes how to effectively identify those affected by DVA and record DVA safely, in emergency care [3], antenatal [4], maternity & sexual health services [5], HIV clinics [6], community gynaecology [7], mental health [8] and primary care [9]. Yet globally, clinicians often do not respond adequately to DVA [10]. Health Care Response to Domestic Violence Essay. In primary care, effective clinical management of common conditions (such as depression or unexplained pain) is not possible if a patient’s experience of abuse remains hidden [11]. IRIS is an evidence based innovative model of care that addresses this gap in healthcare provision and the suboptimal response to DVA in primary care [9].

The IRIS pragmatic cluster randomised controlled trial in 24 intervention and 24 control general practices, in two English cities, showed a three-fold difference in identification of women affected by DVA and a seven-fold difference in referral to specialist DVA services between control and IRIS practices respectively [9]. This was the first evidence that a system level intervention could improve the healthcare response to DVA, by increasing the referrals made of women affected by abuse, to an IRIS advocacy worker (the advocate-educator). A Cochrane review shows that brief advocacy may reduce abuse, improve mental health and quality of life, especially for less severe abuse and in pregnant women [12]. IRIS with its focus on offering women referral for specialist DVA advocacy was also estimated to be cost-effective [13]. Qualitative analysis nested within the original IRIS trial showed that women were positive about being asked about abuse by health professionals and contact with DVA advocates [14]. Health professionals viewed IRIS as an acceptable intervention but had a concern about the four hours’ length of training [15]. Trial results showed a wide variation in DVA identification and referral rates between IRIS practices and amongst clinicians within IRIS practices [9].

Based on the original trial, the IRIS model has been included as an example of best practice in multiple policy and guidance documents, including by NICE [2], the WHO [1], the UK government [16], the Chief Medical Officer [17] and the Home Office [18].

DVA’s health effects are more burdensome than hypertension, obesity, high cholesterol and smoking in women of reproductive age [19]. DVA is the top contributor to death, disability and illness in these women [20]; its management in clinical practice warrants much greater attention. Gynaecological and sexual health problems are the most prevalent and persistent physical health consequence of DVA [21]. Long-lasting mental health problems include depression, anxiety and post-traumatic stress disorder – the most prevalent mental health sequelae [22].

In the UK, since the recession of 2008/09, violent crime against women has increased [23]. Yet between 2008 and 2013, funding for specialist support services’ has decreased by a third [24], despite DVA costing an estimated £11 billion in lost economic output, social services, emotional and medical costs in 2012 [25]. Health Care Response to Domestic Violence Essay.

The IRIS programme was developed as a primary health care contribution to a societal response to DVA, linking general practice to DVA services. The training, support and referral pathway is a complex intervention that enables clinicians to ask about DVA, recognise the DVA in a woman’s life, understand and be able to discuss with her that abuse’s significance to her health whilst providing excellent clinical care, taking the abuse into account and offering a referral to a named specialist within a DVA support service.

Despite the trial evidence, the national policy documents supporting IRIS, and the initial commissioning of IRIS in 34 areas, we do not know whether the programme is sustainable and effective when implemented outside the trial context. We need to determine whether IRIS and its original trial results can be replicated in general practice settings over the longer term. The UK Medical Research Council advises “…effects are likely to be smaller and more variable once the intervention becomes implemented more widely, and…long-term follow-up may be needed to determine whether short-term changes persist” [26].


Primary objective

  1. 1.To measure the effectiveness of IRIS alongside a comparator intervention, in general practice, both designed to improve the healthcare response to DVA in primary care.

Secondary objectives

  1. 2.To understand the process of IRIS implementation, using a mixed methods approach, including survey and qualitative data.
  2. 3.To evaluate IRIS implementation, alongside IRIS’ sustainability, with in depth case studies of two different IRIS areas using interviews, participant observation and document analysis.


A four year observational, pragmatic, mixed methods, implementation MRC phase IV study [27]:

The principal design is a segmented regression analysis of interrupted time series (ITS) data (primarily, referrals received by DVA workers) from general practices that implemented the IRIS intervention and a comparator borough in which the general practices did not implement the IRIS intervention. Health Care Response to Domestic Violence Essay.

There are approximately 386,277 women, aged 16 years and above (patients), registered at the 140 general practices, in the four north-east London implementation borough sites (A, B, C & D), for which IRIS was commissioned; and approximately 77,464 women aged 16 years and above (patients), registered at the 61 general practices, in an adjacent comparator north-east London borough site (E). The comparator borough has not implemented the studied intervention (IRIS) but instead used an alternative DVA initiative, during the time period examined.

Qualitative research is carried out in parallel, including a concurrent embedded, mixed-method process evaluation of IRIS implementation and two in-depth, local, IRIS case studies with a sustainability focus.

All results are integrated, by considering the quantitative and the qualitative results alongside each other, checking that results coincide (for example, are areas with the highest incidence rate ratios for referrals received also the areas in which IRIS has the greatest training reach) whilst reflecting on discordant results, in order to increase understanding about IRIS implementation, sustainability and effectiveness.


This implementation evaluation involves eight sites. Four of these are northeast London borough implementation sites (A, B, C & D) that commissioned IRIS within the study period. One is a comparator northeast London borough site (E) that did not commission IRIS but an alternative DVA initiative. One is an original IRIS trial intervention borough (F) that commissioned IRIS after the original trial. Additionally, an urban northern IRIS area (G) had an IRIS service started within the study period. The personnel involved included all staff at each general practice (clinical and administrative), DVA service providers’ staff and commissioners, including NHS clinical commissioning group staff (clinical leads for child/adult safeguarding and women’s health) and local council staff (concerned with local DVA strategy and public health).


Population/ participants

Sites are invited to take part in this research due to their geographical location in the North Thames area of London, adjoining the original IRIS intervention trial site with a priori knowledge that areas are interested in IRIS commissioning. One IRIS site outside of London is included as a qualitative case study, as it fulfilled pre-specified inclusion criteria of this work (see Appendix A).Health Care Response to Domestic Violence Essay.  IRIS targets women affected by DVA, either currently or historically, from a partner, ex-partner or an adult family member. The eligibility criteria to be included in this observational study are: female patients aged 16 and above, registered at a general practice, at the sites being studied. Women affected by DVA are identified by a clinician and offered a referral to the named IRIS advocate-educator (AE); or women can self-refer to IRIS if they see the publicity material displayed within a surgery.


IRIS is a general practice-based DVA training, support and referral programme for primary care staff. The theoretical framework of the training is based on educational outreach, adult learning theory and peer influence. It was developed using the MRC framework for complex interventions, to improve the primary care response to DVA. This involved steps for development, piloting and testing the intervention in a trial design followed by implementation in routine general practice [26]. Health Care Response to Domestic Violence Essay.