An alarming one in three women experience physical or sexual violence by their partners globally (WHO, 2017) and are significantly more likely to experience depression, anxiety and PTSD (Lambert, 2016). These numbers have definitely not improved with the recent and ongoing COVID-19 crisis, which will almost guarantee a rise in domestic abuse incidents.

Health practitioners can play an important role in recognising and helping victims of domestic violence and abuse (DVA), but they often fail to acknowledge the signs for a number of reasons. These include, but are not limited to, a lack of time, emotional stress and inadequate training from the healthcare system (Moreno et al. 2014).

A recent review explores what both encourages and makes health practitioners ready to address intimate partner violence in their patients (Hegarty et al, 2020). Keyword here: ready — this is what makes the review different to most of the literature, as it involves the feelings, beliefs and attitudes of the practitioners, rather than the physical barriers at play regarding DVA in a healthcare setting. Let’s get to it.

Methods

A qualitative meta-synthesis (relax, there’s no statistics here) was conducted, guided by the research question: what do health practitioners perceive enhances their readiness to address intimate partner violence?

The search was done on MEDLINE; EMBASE; CINAHL; PsychINFO; SocINDEX; ASSIA and the Cochrane Library, and generated 312 results using the keywords intimate partner violence; qualitative research; health practitioners. Quite standard.

Quality appraisal was completed using the Confidence in the Evidence from Reviews of Qualitative research (CERQual) and the Critical Appraisal Skills (CASP) Checklist. The papers were narrowed down to 47 relevant empirical studies including insights from 1,744 practitioners with a range of 4-50 years’ professional experience. The practitioners came from the following areas: Emergency Medicine, Primary Care, Intensive Care, Gynaecology, Maternal and Child Health, Family Planning, Prenatal and Antenatal Medicine, Mental Health, Orthopaedics, Paediatrics, Dentistry and Allied Health.

Results

The authors identified five ways in which health practitioners can improve their readiness to address domestic violence and abuse (DVA).

“Having a commitment”

• The practitioners highlighted that having a personal commitment to DVA boosts their readiness to address the issue.
• This type of commitment can include having personal experience with the matter, or adopting a feminist or human-rights mentality.
• Other practitioners mentioned how prioritising the well-being of children made them more likely to address DVA.

“Adopting an advocacy approach”

• Practitioners spoke highly of not using their position as a health professional to order and command women on what to do regarding DVA.
• Rather, through non-judgement and good listening skills, they want to empower and collaborate with these women to guide them into protection.

“Trusting the relationship”

• Many practitioners felt that the nature of their profession assumed a big piece in their readiness to address DVA — that is, embodying a position of trust, kindness, and confidentiality.
• They explained how they tend to receive positive feedback from women when they bring up potential DVA, and how their clinical role is ideal for responding to victims.

“Collaborating with a team”

• Having a solid foundation of collaboration amongst health practitioners was considered critical in supporting each other emotionally, as well as motivating other practitioners to address DVA.
• Particularly, practitioners spoke about working with specialists, i.e. clinicians with specialist knowledge on DVA.

“Being supported by the health system”

• Last, but definitely not least, health practitioners stressed the significance of being supported by a strong healthcare system.
• Identifying and responding to DVA is something that practitioners felt should be part of their training. This could include scripts of specific sentences to say to patients, or domestic abuse screening as part of a routine assessment process.

The CATCH Model

All these concepts come together to form the CATCH model (Commitment, Advocacy, Trust, Collaboration, Health), which the authors claim is useful for the organisational psychology of healthcare systems. It’s quite CATCH-y, right?

Conclusion

To summarise, the study identified five areas that help practitioners address domestic violence and abuse (DVA):

• Having a personal Commitment to DVA, either from an experience with it or from a feminist or human-rights perspective
• Becoming an Advocate to these women, empowering them to escape these situations
• Being in a position of Trust as a clinician, as patients generally seek hope in professionals in a healthcare setting
• Collaborating with team members and looking for support from specialised DVA clinicians
• Being supported by the Healthcare system, using DVA as part of their training and assessment processes

These findings form what the authors call the CATCH model.

Strengths and limitations

Key strengths include being the first systematic review to explore the readiness of health practitioners to recognise and respond to DVA. Forty-seven studies were included in the review, resulting in insights from a whopping 1,744 practitioners from a wide group of professions.

It’s worth mentioning, however, that the authors considered papers that discussed more tangible barriers to addressing DVA (e.g. lack of time and skills) equivalent to papers that focussed on the attitudes and beliefs of the practitioners. Whilst the two definitely overlap, it would be truer to focus on the internal aspects of practitioners for this review.

On top of that, most of these studies focused on practitioners addressing women, but were limited in responses to men and children. By ignoring men, the study neglects common stereotyping surrounding masculinity that occurs with men experiencing intimate partner violence, which does happen.

Children experiencing DVA is even trickier, as their abusers may be accompanying them to see a GP, making clinicians reluctant to address DVA. Still, as DVA against women is considered a public health crisis, particularly intimate partner violence, this demographic focus is deserved (WHO, 2017). The recent Safe Seen Supported report on how to reach and help children and young people experiencing abuse in their households, is well worth a read.

The authors do mention a limitation of this review regarding how most studies were performed in high-income countries. This makes it difficult to generalise to lower-income countries where healthcare systems are less well-developed.

A limitation not recognised is the lack of cultural diversity in these studies, with only five non-Western studies. Not only do healthcare systems differ dramatically across the world, but so do the cultural conventions between patients and clinicians (Galanti, 2000). It’s almost as if the Western World isn’t the centre of the universe? Who would have thought…

Implications for practice

This study has useful insights and the CATCH model adds to the literature of health practitioners addressing DVA. The model may be useful for practitioners to use in their early studies, or by implementing it in the NHS’ Safeguarding policies to promote self-awareness. It can also be useful for managerial staff in tackling any uneasiness amongst employees regarding DVA.

At the end of the day, health practitioners are individuals and their attitudes and beliefs can directly influence their practice. Having a commitment, adopting an advocacy approach, and trusting the relationship are valuable perspectives that can inspire others to address DVA worldwide, particularly as women (both survivors and non-affected) feel it is appropriate to be asked about DVA, and see their GP as one of the few people they can disclose their experiences to (Feder at al. 2006).

However, shifting the focus entirely from more tangible barriers and facilitators can be harmful. Undoubtedly, these cannot be ignored as we’ve seen in being supported by the healthcare system.

So, what are the real magic words here? Multidisciplinary teams (MDT). MDT’s are important in detecting DVA, as shown in collaborating with a team and earlier literature (Basu & Ratcliffe, 2014). Safeguarding nurses, social workers, and DVA service referrals are incredibly useful in the delicate handling and escalation of DVA. Not only that, but they also provide staff with confidence and better detection capabilities. Teamwork makes the dream work, after all.

Living in a Western high-GDP country, we are lucky to have specific policies in place that target DVA in a healthcare setting, and these include the use of MDT’s. The NHS has guidance for general practitioners in developing their own DVA policies, which include forming solid relationships with local DVA services and providing referrals to these facilities (Tomlin, 2012). Sadly, with the absence of a universal screening assessment, many countries lack these policies despite healthcare systems playing a major role in identifying DVA.

Now more than ever, there’s no time for complacency. With a surge in COVID-19 cases, lockdowns and virtual GP consultations, more and more individuals affected by domestic violence and abuse (DVA) are going unnoticed. Introducing the CATCH model at this time may give health services the necessary nudge in being more mindful of DVA in their patients, and continuing the use of MDT’s. Future research should determine any association between the use of CATCH and improved detection rates.

Conflicts of interest

The author of this blog (Melisa Eyuboglu) has had no involvement in this study and declares no conflicts of interest.

King’s MSc in Mental Health Studies

This blog has been written by a student on the Mental Health Studies MSc at King’s College London. A full list of blogs by King’s MSc students from can be found here, and you can follow the Mental Health Studies MSc team on Twitter.

We regularly publish blogs written by individual students or groups of students studying at universities that subscribe to the National Elf Service. Contact us if you’d like to find out more about how this could work for your university.

Links

Primary paper

Hegarty K, McKibbin G, Hameed M. et al (2020). Health practitioners’ readiness to address domestic violence and abuse: A qualitative meta-synthesis. PloS one, 15(6).

Other references

Basu S, Ratcliffe, G. (2014). Developing a multidisciplinary approach within the ED towards domestic violence presentations. Emergency Medicine Journal, 31(3), 192.

Feder G, Hutson M, Ramsay J. et al (2006). Women exposed to intimate partner violence: expectations and experiences when they encounter health care professionals: a meta-analysis of qualitative studies. Arch Intern Med, 166(1), 22-37.

Galanti G. (2000). An introduction to cultural differences. Western Journal of Medicine, 172(5), 335–336.

Lambert N. Violence and women’s mental health: new review summarises the evidence. The Mental Elf, 16 December, 2016

Moreno C, Hegarty K, d’Oliveira A. et al (2014). The health systems response to violence against women. The Lancet, 385(9977), 1567–79.

ONS (2020). Child abuse extent and nature, England and Wales: year ending March 2019. Office for National Statistics website, January, 2020.

Tomlin A. New guidance on domestic abuse from the Royal College of General Practitioners. The Mental Elf, 29 May 2012

WHO (2017) Violence against women. World Health Organisation website, November, 2017.

Photo credits

• Photo by TRAVIS NESBITT on Unsplash
• Photo by Anthony Tran on Unsplash
• Photo by Natalie Hua on Unsplash
• Photo by Anthony Duran on Unsplash
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