International Domestic Violence and Health Conference 2018 Aims and Launch Kelsey Hegarty (University of Melbourne and Royal Women’s Hospital) Please engage with us throughout the conference via: Twitter: • Tag us @safer_families and use the conference hashtag #DVandHealth2018 • Support the United Nations 16 days of activism using the hashtag #HearMeToo
Audience Poll: • Go to our IDVH Poll at www.pollev.com/IDVH2018 and have this link ready on your devices during the Conference
#DVandHealth2018
IDVH Conference Committee Kinship, Culture and Connections IDVH Sub-committee • Kelsey Hegarty – The University of Melbourne • Karen Glover – SAHMRI • Stephanie Brown – Murdoch Children’s Research • Kerry Arabena – University of Melbourne Institute • Stephanie Brown – Murdoch Children’s Research • Elizabeth (Libby) Hindmarsh – RACGP Institute • Karen Glover – SAHMRI • Shawana Andrews – University of Melbourne • Jane Koziol-McLain – Auckland University of • David Gallant – The University of Melbourne Technology • Renee Fiolet – The University of Melbourne • Laura Tarzia – The University of Melbourne • Renee Fiolet – The University of Melbourne • Jacqui Cameron – The University of Melbourne Special Mention to Resource Staff • Amanda Wallace – WEAVERS panel • Alexandra Wilson • Fiona - WEAVERS panel • Kitty Novy • Simone Gleeson – The University of Melbourne • Rhian Parker www.pollev.com/IDVH2018 #DVandHealth2018 Welcome to Country
Aunty Dianne Kerr
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#DVandHealth2018 Story-telling begins
WITH Project Well-being begins
Kundalini House
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#DVandHealth2018 WEAVERS: Launch of Conference Women and their children who have Experienced Abuse and Violence Researchers and advisers PRESENTER: Zofia Di Stephano
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#DVandHealth2018 We want to hear from you: Laura Tarzia (University of Melbourne) What is the priority for change in the early intervention and health system space?
Write one or two words and need to connect words with an underscore.
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#DVandHealth2018 Panel Discussion Early intervention in the health sector for the whole family CHAIR: Kelsey Hegarty PANELISTS: Claudia Garcia-Moreno Suchitra Chari Jackie Ah Kit Elizabeth Hindmarsh
Jane Koziol-McLain www.pollev.com/IDVH2018
#DVandHealth2018 Performance ‘Cleaving’ A duet illustrating opposing processes in trauma and recovery PERFORMERS: Nilgun Guven (Dancer) Cindy Watkin (Viola Player)
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#DVandHealth2018 Refreshment and Wellbeing Break Please make your way down to Level 2 Pavilion Wellbeing Session Massage – Pavilion Level 2 Engagement Twitter @safer_families, #DVandHealth2018 Polling link www.pollev.com/IDVH2018 I wish tree…….. Reflections Box www.pollev.com/IDVH2018
#DVandHealth2018 International Domestic Violence and Health Conference 2018 Q and A Panel Early Intervention in health sector CHAIR: Harriet MacMillan PANELISTS: Gene Feder Marsha Uppill Rachael Green Leesa Hooker
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#DVandHealth2018 Early intervention in health sector: the IRIS story
Gene Feder
International Domestic Violence and Health conference November 20th 2018 primary care at the centre
Secondary and tertiary care
Community General practice
Social care Specific primary health care response?
. contact of whole population with primary care . morbidity in primary care populations How do we engage general practice?
. cluster randomised controlled trial . 1 year follow up . 48 practices in Bristol and Hackney Identification and referral to Improve Safety IRIS model
Training and support + referral Health pathways education including material safeguarding + Advocacy Less Clinical children and Identification abuse enquiry Emotional adults + + + & improved Medical record Validation Referral Practical quality prompts + support of life + Documentation + Recording and + mental flagging Immediate risk health system check and + safety Advocate assessment educator + Practice champion crucial partnership with domestic violence advocacy organisations
NextLink & the nia project
. advocate educator . specialist referral service . link to local domestic violence fora and coordinated community response
IRIS trial results (very) cost-effective
. NHS cost savings of £1.07per woman per year, equivalent to UK £3155 per practice per year . societal cost savings of £37/woman/year beyond the ivory tower translation into policy . cited in Department of Health Violence Against Women and Children taskforce report as an exemplar programme . cited in WHO partner violence guidelines as evidence for recommendation on training interventions . part of NICE domestic violence guidelines evidence review . cited as a “particularly effective remedy” by the Task and Finish Group for the Welsh Government’s proposed ‘Ending Violence Against Women and Domestic Abuse (Wales) Bill’ commissioning guidance Scotland sites: sites: Scotland - Borders - Edindgurgh area - Glasgow area Northumberland - Lanarkshire Current IRIS sites - West L:othian
Cumberland Durham
Westmorland
North Riding
Yorkshire East Riding Lancashire West Riding Bolton Salford Manchester Trafford Mansfield & AshfieldLindsey Cheshire west East Cheshire Cheshire Derby Vale royal and South Notts Cheshire Nottingham Lincoln westNottingham CityKesteven , Stafford Holland Norfolk Leicester Rutland Shropshire Birmingham Sandwell Huntingdon And Warwickshire Peterborough Wales Northants Worcester Cambridge West East And Isle of Ely Suffolk Hereford Bedford
Cwm Oxford Bucks Taf Gloucester Hertford Essex London sites: - Hackney - Lambeth Cardiff and the ValeBristol Greater South Berkshire west - Enfield Berks Reading & London Gloucester - Camden North Somerset Wiltshire Wokingham - Islington Bath and North East Surrey East Surrey Kent - Tower Hamlets Somerset Hampshire - Bromley Somerset - Lewisham Sussex - Southwark Southampton West East Devon Dorset Portsmouth Poole Isle of Wight Cornwall IRIS into practice
. commissioned by CCGs and local authorities in 32 English localities and 2 Welsh health boards . >60 advocate educators and >50 clinical leads trained in England . > 1000 general practices trained . Total IRIS practice referral to specialist agencies is > 12000 Continuing effect?
Beyond primary care?
. LARA (Linking Abuse and Recovery through Advocacy) . irisADVISE (Assessing for Domestic Violence in Sexual health Environments) . irisPharm What about men & children? IRIS +
Workstream I of the REPROVIDE Programme Enlarging the IRIS model beyond women survivors of domestic violence
IRIS+ Phase 3 Phase 1 Phase 2 Pilot Evidence Development Phase 4 Phase 5 Adjustments Consultation Consultation Trial Nested studies Interim Development Protocols Report 2016Systematic 2016Training-17 and AE Training2017-18 pilot 2018Cluster-20 2018Nested-21 review of role delivery with randomised trial qualitative study interventions for development observation (24 control and of programme male victims 24 intervention implementation Protocol and Pilot interviews practices) Mapping study of data collection Mixed-method services for men development Pilot Agency and study (interviews victims and questionnaires practice data and children Consultations analysis questionnaires) Adjustments to Training and AE Pre-pilot training, referral Cost- Analysis, role development delivery pathway, AE role, effectiveness synthesis, report, trial data analysis dissemination Consultations Pilot practice collection tools Consensus recruitment and protocols process
IRIS+
Thank you
to survivors to their families to colleagues to funders Lunch and Wellbeing Break Please make your way down to Level 2 Pavilion Wellbeing Session Singing – Bayside 4A Level 2 (25 mins from 1pm) Massage – Pavilion Level 2 Table Conversations A-sis-stance – an action group for Women Early Intervention Culture, Kinship and Connection www.pollev.com/IDVH2018 Children and Young People #DVandHealth2018 International Domestic Violence and Health Conference 2018 Q and A Panel Dynamics and complexity of abuse and resilience CHAIR: Jo Spangaro PANELISTS: Stephanie Brown Fiona Carmel O'Brien Karen Glover
Nancy Glass www.pollev.com/IDVH2018
#DVandHealth2018 Dynamics and complexity of abuse and resilience
INTERNATIONAL DOMESTIC VIOLENCE & HEALTH CONFERENCE 20 NOVEMBER 2018 STREAM 2 STEPHANIE BROWN Overview
•Snapshot of findings from 2 studies
•Rethinking role of health services in promoting the health and wellbeing of women, children and families Intergenerational Health
OUR VISION: Health, wellbeing and equity for mothers, children and families
Prospective pregnancy cohort: 1507 first time mothers and first born children
Prospective birth cohort: 344 Aboriginal families in urban, regional and remote areas of South Australia 1507 first time mothers & first born children Intimate partner violence
In the last 12 months, has a partner or ex-partner…
• pushed, grabbed or shoved you • shook you • beat you up • blamed you for causing their violent behavior • tried to turn family, friends of children against you • told you no one would want you …?
Composite Abuse Scale Short version, 18 items measuring physical and emotional abuse (Hegarty K et al)
344 Aboriginal families in SA
FIRST 12 MONTHS
5
- 6 6 YEARS 344 Aboriginal families in SA
During your pregnancy, did any of the following things happen to you? • Scared of other people’s behavior • Left home because of family argument • Upset by family arguments • Pushed, shoved or assaulted
In the last 12 months, has a partner or expartner … • Told you that you are crazy (boontha) • Stopped you from connecting with your Aboriginality (e.g. going to community events) • Slapped or hit you • Flogged you • Took money from your bank account ….? Prospective pregnancy cohort: 1507 first time mothers and first born children Physical and mental health in first 4 years after childbirth
of women experience 90% of women 29% experience exhaustion physical and/or emotional intimate partner 73% of women have violence recurrent back pain
More than 30% of of women 52% women experience experience of women depressive or anxiety urinary incontinence 33% experience symptoms sexual health issues Physical health and mental health are linked
90% of women experience exhaustion
73% of women have Women experiencing 3 recurrent back pain or more physical health issues are 52% of women experience urinary incontinence 3x more likely to be depressed
33% of women experience sexual health issues Social context matters
4x more likely to be depressed if on a very low income 6x more likely to be depressed if experiencing 3 or more stressful life 5x more likely to be events/social health issues depressed if experiencing intimate partner violence Implications for primary care
2 out of 5 women with depressive symptoms are experiencing intimate partner violence Implications for children
1 in 4 children
Children growing up exposed to intimate partner violence are 3 x more likely to experience emotional and behavioural exposed to family difficulties at age 4 violence by age 4 Prospective birth cohort: 344 Aboriginal families in urban, regional and remote areas of South Australia Common experiences during pregnancy
Upset by family arguments 55
Scared of other people's behaviour 31
Left home because of family argument 27
Pushed, shoved, assaulted 16
% 0 20 40 60 80 Most common social issues in pregnancy
Upset by family arguments 55 Housing problems 43 Family/friend passed away 41 Pestered for money 31 Scared of other people's behaviour 31 Left home because of family argument 27 Very sick/badly injured 24 Partner: problems drugs or alcohol 22 Had to stop working/studying 16 Pushed, shoved, assaulted 16 Problems with police, going to court 13 Problems with drugs or alcohol 9 % 0 20 40 60 80 WHAT KEEPS WOMEN STRONG What enables women to stay strong and protect themselves and their children? In summary ….
• Intimate partner violence is both a serious public health and human rights issue
• At least as common as maternal depression, and potentially more devastating impact Implications for intervention
• WHO recommends screening and tailored first line responses in antenatal care & strengthening the capacity of primary care and early childhood services to respond
• Royal Commission into Family Violence: urgent need to strengthen health sector responses Implications for intervention
• Co-occurrence of intimate partner violence with other social health issues (e.g. housing, drug & alcohol)
• Need for a multi-faceted health sector response tailored to social context Acknowledgements
• Maternal Health Study team • Aboriginal Families Study team Thank you! • Aboriginal Health Council of South Australia • Aboriginal Advisory Group members • NH&MRC “Trauma informed services assume that people are doing the best they can at any given time to cope with the life altering and frequently shattering effects of trauma." Unaiza Niaz Refreshment and Wellbeing Break Please make your way down to Level 2 Pavilion Wellbeing Session Yoga – plenary Level 17 (15 mins from 3pm) Massage – pavilion level 2 Singing bowl meditation – nurturing space level 17 (10 mins from 3pm) Six pillars of thriving – bayside 5 level 17 (20 mins from 3.05pm) Engagement Twitter @safer_families, #DVandHealth2018 Polling link www.pollev.com/IDVH2018 www.pollev.com/IDVH2018 I wish tree…….. Reflections Box #DVandHealth2018 International Domestic Violence and Health Conference 2018 Paper Presentations Primary Care
CHAIR: Jane Koziol-McLain
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#DVandHealth2018 Insights on sustaining primary healthcare responses to intimate partner violence
PRESENTER: Claire Gear
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#DVandHealth2018 Insights on sustaining primary care responses to intimate partner violence Claire Gear, PhD Candidate AUT Vice Chancellor Doctoral Scholarship Recipient Centre for Interdisciplinary Trauma Research, AUT University, New Zealand
With thanks to study advisors: Professor Jane Koziol-McLain, Dr Elizabeth Eppel Dr Clare Healy, Dr Anna Rolleston & Ngati Ranginui kaumatua Tamati Tata Background
Integrating effective and sustainable health care responses to IPV has proven challenging internationally New Zealand Violence Intervention Programme (VIP) Supports responses to IPV and child abuse and neglect in hospital and selected community settings. Similar engagement with primary health care has been limited. What affects a sustainable response to IPV within New Zealand primary health care settings? Complexity Theory
Often used to reconceptualise health systems as complex adaptive systems (CAS) Focuses on the interaction between system elements (agents) Agents learn, act and respond to the actions of others (co- evolution) Patterns of interaction lead to spontaneous new behaviours (self-organisation) Over time leads to new system structure (emergence) Uncertainty
Number and diversity of agent interactions makes it difficult to predict how things will unfold
Interactions can generate unintended effects
‘Sometimes you have a very minor intervention that has a big change, and sometimes you can hit people over the head and it doesn’t seem to make any difference.’ (Crabtree, 2010, p.124). Study design
Hypothesized: A sustainable response to IPV emerges from the patterns of interaction between agents (e.g. patient and health professional)
Complexity-informed discourse analysis of Functional analysis of key policy, strategy, guideline, evaluation documents (n=110) Health Professional Interviews (n=17; 4 general practices) Respond, Response, Responsiveness CAS
Respond. How a health professional may interact with IPV depending on who they are (e.g. worldview, model Respond Response of care).
Response. Known formal or informal options available to the health professional to address IPV.
Responsiveness. Generation of Responsiveness satisfactory outcomes for both patient and health professional. Doctor:
Respond stance: Why I don’t address IPV
Response discourse: ‘I try to ask the question’
Responsiveness: What do you do when you’re aware of it but don’t know where to go with it? Doctor: Respond
‘I think obviously a lot of the stuff comes from social ills. It’s happening in families where there is unemployment and overcrowding. Clearly that’s the root of it and if we were to stop it that’s what would need to be addressed.’ Doctor:
Respond stance: Why I don’t address IPV
Response discourse: ‘I try to ask the question’
Responsiveness: What do you do when you’re aware of it but don’t know where to go with it? Doctor: Response
‘I try to ask the question, although at the moment it’s on an ad hoc basis [...] The other issue is responding to it when it’s been disclosed. There’s a limited number of resources I guess to use. Often women unfortunately aren’t keen to use them because they don’t want to lose their home I guess. […] I listen to the patient’s concerns, try to hear them as well as possible, offer solutions in terms of leaving the home. […] Yeah, I think that’s probably the guts of it at the moment.’ Doctor:
Respond stance: Why I don’t address IPV
Response discourse: ‘I try to ask the question’
Responsiveness: What do you do when you’re aware of it but don’t know where to go with it? Doctor: Responsiveness
‘I guess the problem is if it comes to you from a third party. Another nurse, or another doctor, or indeed a relative. It’s hard to know how to respond to that. The woman herself hasn’t brought it up, she may not want it brought up. Doing so, although obviously one wants to deal with it, might be counter-productive in terms of the relationship with her and me. So that’s a very real challenge, and of course the relationship with her partner who may also be a patient of mine.’ Implications
The meaning of what a ‘response’ is will be rearticulated by individuals and organisations.
Understanding IPV as a key determinant of ill-health is essential
Need to consider how interactions at different system levels block responsiveness.
CAS approach can be used to identify blockages and opportunities which we may intervene in to amplify or diminish effects Would appreciate feedback
Claire Gear, PhD Candidate Centre for Interdisciplinary Trauma Research AUT University, New Zealand [email protected] Harmony - bilingual GP/advocate systems model in migrant communities
PRESENTER: Angela Taft
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#DVandHealth2018 MABELS: a practice-informed model in early intervention family violence support
PRESENTER: Marika Manioudakis Anita Koochew
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#DVandHealth2018 Working with men who use violence in relationships: GPs' experiences
PRESENTER: Laura Tarzia
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#DVandHealth2018 Shannah Mousaco, Laura Tarzia, Kirsty Forsdike & Kelsey Hegarty (The University of Melbourne) Severity of intimate partner physical abuse and formal help-seeking behaviour
PRESENTER: Kim Carmela Co
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#DVandHealth2018 Severity of intimate partner physical abuse and formal help-seeking among women in the Philippines of ever-partnered women experienced physical abuse 13% from their intimate partners reported being either punched, kicked, dragged, beat 53% up, choked or burned on purpose, or threatened or attacked with a knife, gun, or other weapon only 4% sought help from formal services Women who experienced severe physical abuse were approximately 5 times as likely* to seek medical or legal assistance compared to those who experienced moderate physical abuse. (OR=4.58, 95%CI: 1.87-11.25) *Adjusted for age, wealth index, educational attainment, employment status, type of IPV experienced, partner’s alcohol consumption, marital control, and perceived justification of abuse Public trust in the Brazilian VAW legal and health response
PRESENTER: Dabney Evans
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#DVandHealth2018 “They fear the law more than the perpetrators”: Public trust in Brazilian legal & health sector response to Violence against Women Dabney P. Evans, PhD, MPH; Jasmine D. Wilkins, MPH, Ellen D. Chiang, BS; Maria AF Vertamatti
Purpose Results Conceptual Framework
To examine the relationship between women’s perceptions of federal VAW laws, & their trust in Also, the government…it gets worse health & legal sector response to intimate partner and worse…I’m never going to vote violence in Santo André, Brazil for anyone ever again. …I’m going to void my vote Background Governm Today it has turned into, ‘Oh, you got ent is not a Maria da Penha charge, so what?’ trusted & • Despite several federal Violence Against Women (VAW) You know? the legal laws in Brazil half (50%) of its citizens believe that the way the justice system punishes perpetrators does not system is The Maria da Penha law captures reduce such violence. [1] ineffectua them [perpetrators], the justice…legal l system frees them. • Little is known about how general perceptions of the government may impact women's perceptions and understanding of VAW laws, legal or medical services People know the laws, right, but it seems meant to prevent and address VAW. like women fear the law more than the perpetrators. VAW Conclusions Exposurelaws of the dopaminergic All concentrations of HBCD tested Methods We see a lot of cases where the woman neuroblastomadon’t cell line, SK-N-SH, to yielded significant increases in reactive HBCD caused a dose-dependentgoes, reports, andoxygen the species police production do nothing, compared Widespread lack of trust in the government may Study site: decreaseprotect in cell viability. and two, threeto months DMSO treated later cells.you receive have an effect on women's perceived efficacy for • Santo André, a municipality of 700,000 in metropolitan women the news that the person was murdered VAW response in the health & legal sectors & may São Paulo, Brazil. The Secretariat of Women’s A. by the husband,B. understand? But she exacerb went back, she tried, she reported it, but Policies and Ministry of Health were partners. VAW laws are necessary but not sufficient; they ate no… must be operationalized violence Data collection: It doesn’t work because…the guy gets Distrust blocks two major pathways for responding • 30 In-depth interviews (IDIs): locked up, then when he gets out he to VAW • Women aged 18 and older living in Santo André goes there and kills the woman. • Recruited at 3 health clinics ‘She has a lot of kids, time to close Multi sectoral responses are necessary especially in • Main topics: the factory, you here having all countries where public health services are largely C. Individual experiences & community perceptions these kids here and there.’ And ID. State endeavors. of VAW stayed there in the health post, I DMSO 10 μM HBCD Health care access & quality started crying there in the health Satisfactio Knowledge of & opinions about federal VAW post..I do not like to talk about the Acknowledgeme n with legislation [health] post because it offended nts . me a lot … what this girl did to me, health Data analysis: humiliated me a lot.. She services • Emory University Global Health Institute and Emory University Research Committee • Modified grounded theory of themes using MAXQDA12 humiliated worse than a dog. is mixed • Participants and Research Team: Dani Matias, Casey D. Hall, Nancy de Sousa Williams, Maryclaire Regan
Study ethics: ExposureThe doctors of TH+ ventral here, mesencephalic the nurses,primary are cultured neurons to HBCD caused References: 1. Data Popular, Instituto Patrícia Galvão. Percepção da sociedade sobre • Approved by Emory University Institutional Review dosevery-dependent nice, understanding, alterations of neuron and characteristics. very Treatment of primary culturesattentive, caused too; significantthe problemdecreases initself the number is of TH+ neurons, as well as violência e assassinatos de mulheres. 2013. [http://agenciapatriciagalvao.org.br/wpcontent/uploads/2013/08/livro_pesquisa Board & Plataforma Brasil (CAAE significantthe delay reductions of the in TH+ service...That neurite length and is number of TH+ neuron branch 57344616.0.0000.5484 points per TH+ neuron. _violencia.pdf] Accessed 18 June 2017 http://agenciapatriciagalvao.org.br/wp- the difficulty. content/uploads/2013/08/livro_pesquisa_violencia.pdf • WHO Guidance on conducting VAW research was used throughout. What factors influence the decision to report child abuse?
PRESENTER: Jacqueline Kuruppu
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#DVandHealth2018 What factors influence GPs’ and practice nurses’ decision to report child abuse? Jacqueline Kuruppu Supervisors: Professor Kelsey Hegarty, Professor Cathy Humphreys, Dr Gemma McKibbin Background Method Preliminary findings
PhD aims to design a decision- • Child age, injury severity, making tool to help in reporting Case explanation child abuse 4 Databases Elements 779 articles
• Building evidence before reporting GPs and practice nurses lack 71 Full- Lacking • Not enough evidence, no reporting support when reporting child abuse evidence text
33 • Difficulties recognizing certain types of abuse articles Lacking • On reporting processes What factors influence the decision included knowledge to report child abuse? Reaching Children Through Universal Services - evidence- informed children's therapeutic program
PRESENTER: Lianna Muscat
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#DVandHealth2018
What is RCUS
• RCUS is an evidence-informed, demonstration project funded by the Department of Health and Human Services (Vic) as part of the Family Violence Therapeutic Interventions projects.
• It is a service for children and young people, aged 0-18 years, who have experienced family violence.
• It is a voluntary service at no cost
• Support may continue for up to 12 months Partners Staffs are co-located to ensure that services are delivered in locations best suited and least disruptive to the child • For 0 -4 years: Brimbank City Council, Maternal and Child Health, Melton City Council • For 5-12 years: St Albans Primary School • For 12-18 years: Kurunjang Secondary College • For 0-18 years: Community Hub The aims of RCUS are to:
Therapeutic groups Circle of Security - evidence based Tuning Into Kids – evidence based Children’s groups – Evidence informed therapeutic group
Outcomes: • Strong attendance and engagement • High proportion of CALD clients • Family Violence focus Community capacity-building
• Training session with school staff – focusing on understanding and working with developmental trauma and strategies • Over 100 staff attended • 100% satisfaction in feedback • 47 secondary consults Outcomes
• Constant waiting list, demonstrates the unmet need in the community • EMDR and equine therapy • Targets already exceeded before year end • Strong engagement rates with hard-to-engage clients • Strong relationships with partners and community “an onsite social worker that can make connections with families within the school community and build relationships with the children and families in a familiar environment. This program supports the school to provide high quality education for all students.” Next Steps
• Extension of funding for a second year of project • All 5 partners have signed up for the second year • DHHS evaluation through EY Sweeney underway • University of Melbourne evaluation commencing THANK YOU FOR YOUR TIME! International Domestic Violence and Health Conference 2018 Priority setting exercise and closing reflections
Kelsey Hegarty and Shawana Andrews
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#DVandHealth2018 We want to hear from you: Laura Tarzia (University of Melbourne)
What is the priority for change in the early intervention and health system space?
Please rank the priorities.
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#DVandHealth2018 Welcome Reception – Get to know you drinks Please make your way out to the Level 17 Foyer
Tickets will be collected at the door for the welcome reception from those that have selected to attend to ensure your complimentary drink.
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#DVandHealth2018 International Domestic Violence and Health Conference 2018