Kathleen Baird

Identification and Referral to Improve Safety (IRIS) of women experiencing domestic violence with a primary care training and support programme: a cluster randomised controlled trial

BACKGROUND Most clinicians have no training about domestic violence, fail to identify patients experiencing abuse, and are uncertain about management after disclosure. We tested the effectiveness of a programme of training and support in primary health-care practices to increase identification of women experiencing domestic violence and their referral to specialist advocacy services. METHODS In this cluster randomised controlled trial, we selected general practices in two urban primary care trusts, Hackney (London) and Bristol, UK. Practices in which investigators from this trial were employed or those who did not use electronic records were excluded. Practices were stratified by proportion of female doctors, postgraduate training status, number of patients registered, and percentage of practice population on low incomes. Within every primary care trust area, we randomised practices with a computer-minimisation programme with a random component to intervention or control groups. The intervention programme included practice-based training sessions, a prompt within the medical record to ask about abuse, and a referral pathway to a named domestic violence advocate, who also delivered the training and further consultancy. The primary outcome was recorded referral of patients to domestic violence advocacy services. The prespecified secondary outcome was recorded identification of domestic violence in the electronic medical records of the general practice. Poisson regression analyses accounting for clustering were done for all practices receiving the intervention. Practice staff and research associates were not masked and patients were not aware they were part of a study. This study is registered at Current Controlled Trials, ISRCTN74012786. FINDINGS We randomised 51 (61%) of 84 eligible general practices in Hackney and Bristol. Of these, 24 received a training and support programme, 24 did not receive the programme, and three dropped out before the trial started. 1 year after the second training session, the 24 intervention practices recorded 223 referrals of patients to advocacy and the 24 control practices recorded 12 referrals (adjusted intervention rate ratio 22·1 [95% CI 11·5-42·4]). Intervention practices recorded 641 disclosures of domestic violence and control practices recorded 236 (adjusted intervention rate ratio 3·1 [95% CI 2·2-4·3). No adverse events were recorded. INTERPRETATION A training and support programme targeted at primary care clinicians and administrative staff improved referral to specialist domestic violence agencies and recorded identification of women experiencing domestic violence. Our findings reduce the uncertainty about the benefit of training and support interventions in primary care settings for domestic violence and show that screening of women patients for domestic violence is not a necessary condition for improved identification and referral to advocacy services. FUNDING Health Foundation.

Primary care Identification and Referral to Improve Safety of women experiencing domestic violence (IRIS): protocol for a pragmatic cluster randomised controlled trial

BackgroundDomestic violence, which may be psychological, physical, sexual, financial or emotional, is a major public health problem due to the long-term health consequences for women who have experienced it and for their children who witness it. In populations of women attending general practice, the prevalence of physical or sexual abuse in the past year from a partner or ex-partner ranges from 6 to 23%, and lifetime prevalence from 21 to 55%. Domestic violence is particularly important in general practice because women have many contacts with primary care clinicians and because women experiencing abuse identify doctors and nurses as professionals from whom they would like to get support. Yet health professionals rarely ask about domestic violence and have little or no training in how to respond to disclosure of abuse.Methods/DesignThis protocol describes IRIS, a pragmatic cluster randomised controlled trial with the general practice as unit of randomisation. Our trial tests the effectiveness and cost-effectiveness of a training and support programme targeted at general practice teams. The primary outcome is referral of women to specialist domestic violence agencies. Forty-eight practices in two UK cities (Bristol and London) are randomly allocated, using minimisation, into intervention and control groups. The intervention, based on an adult learning model in an educational outreach framework, has been designed to address barriers to asking women about domestic violence and to encourage appropriate responses to disclosure and referral to specialist domestic violence agencies. Multidisciplinary training sessions are held with clinicians and administrative staff in each of the intervention practices, with periodic feedback of identification and referral data to practice teams. Intervention practices have a prompt to ask about abuse integrated in the electronic medical record system. Other components of the intervention include an IRIS champion in each practice and a direct referral pathway to a named domestic violence advocate.DiscussionThis is the first European randomised controlled trial of an intervention to improve the health care response to domestic violence. The findings will have the potential to inform training and service provision.Trial registrationISRCTN74012786

A five year follow-up study of the Bristol pregnancy domestic violence programme to promote routine enquiry

OBJECTIVE a follow-up study to evaluate the degree to which practice changes identified in the 2004/2005 evaluation of the Bristol Pregnancy Domestic Violence Programme (BPDVP) for routine enquiry for domestic abuse have been maintained. METHODS a multimethod approach was adopted, using a follow-up survey and focus groups. SETTING an acute Trust within the South West of England. PARTICIPANTS 58 midwives completed the survey, 73% (n=36) of whom had taken part in the original study in 2004/2005. Eleven of those surveyed also participated in focus group interviews. MEASUREMENTS participating midwives completed a 54-item questionnaire, where possible the questions were the same as those utilised in the original follow-up questionnaire. Similar to the previous study, the questionnaire was divided into a number of sections, including view of professional education, knowledge of domestic violence and abuse, attitudes and efficacy beliefs, barriers and support. The aim of the focus groups discussion was to obtain the overall views of midwives with the regard to the on-going implementation of routine enquiry. Frequency distributions for midwife responses in 2010 were compared with the corresponding frequency distributions in 2004/2005 and a statistical assessment of differences was performed using the χ(2) test of association. RESULTS midwives have to feel confident in their abilities to ask about abuse and the findings from this study demonstrate that across the cohort there was a tendency to have an increase in confidence in asking about domestic violence. Midwives have to feel confident in their abilities to ask about abuse. The findings from this study demonstrate that across the cohort there was a statistically significant increase in self-reported confidence in asking women about domestic abuse. In addition, there was a statistically significant increase in the degree of self-reported knowledge of how to deal with a disclosure of domestic violence when comparing the 2010 data with 2005 data. CONCLUSIONS results suggest that improvements in antenatal enquiry for domestic violence and abuse developed through the 2004/2005 BPDVP have improved over time, with the support of mandatory training. Nevertheless, barriers continue to exist, which include presence of a male partner and lack of face to face interpreting services, both these obstacles need to be addressed if all women and, in particular those who are most at risk of abuse are to be identified and supported.

Intimate partner violence around the time of pregnancy and postpartum depression: The experience of women of Bangladesh

Background and objectives Intimate partner violence (IPV) around the time of pregnancy is a serious public health concern and is known to have an adverse effect on perinatal mental health. In order to craft appropriate and effective interventions, it is important to understand how the association between IPV and postpartum depression (PPD) may differ as a function of the type and timing of IPV victimization. Here we evaluate the influence of physical, sexual and psychological IPV before, during and after pregnancy on PPD. Methods Cross-sectional survey data was collected between October 2015 and January 2016 in the Chandpur District of Bangladesh from 426 new mothers, aged 15–49 years, who were in the first six months postpartum. Multivariate logistic regression models were used to estimate the association between IPV and PPD, adjusted for socio-demographic, reproductive and psychosocial confounding factors. Results Approximately 35.2% of women experienced PPD within the first six months following childbirth. Controlling for confounders, the odds of PPD was significantly greater among women who reported exposure to physical (AOR: 1.79, 95% CI [1.25, 3.43]), sexual (AOR: 2.25, 95% CI [1.14, 4.45]) or psychological (AOR: 6.92, 95% CI [1.71, 28.04]) IPV during pregnancy as opposed to those who did not. However, both before and after pregnancy, only physical IPV evidences a direct effect on PPD. Results highlight the mental health consequences of IPV for women of Bangladesh, as well as the influence of timing and type of IPV on PPD outcomes. Conclusions and implications The findings confirm that exposure to IPV significantly increases the odds of PPD. The association is particularly strong for physical IPV during all periods and psychological IPV during pregnancy. Results reinforce the need to conduct routine screening during pregnancy to identify women with a history of IPV who may at risk for PPD and to offer them necessary support.

Women's views and experiences of antenatal enquiry for domestic abuse during pregnancy

The aim of this study was to explore the acceptability of antenatal enquiry for domestic abuse from the perspective of women using maternity services. It also sought to understand the experiences of referral and support offered to women who had positively disclosed abuse.

Exploring the associations between intimate partner violence victimization during pregnancy and delayed entry into prenatal care: Evidence from a population-based study in Bangladesh

OBJECTIVE Intimate partner violence (IPV) during pregnancy can have serious health consequences for mothers and newborns. The aim of the study is to explore: 1) the influence of experiencing IPV during pregnancy on delayed entry into prenatal care; and 2) whether womens decision-making autonomy and the support for traditional gender roles act to mediate or moderate the relationship between IPV and delayed entry into prenatal care. DESIGN cross-sectional survey. Multivariate logistic regression models were estimated that control for various socio-demographic and pregnancy related factors to assess whether women who experienced IPV during pregnancy were more likely to delay entry into prenatal care compared with women who had not experienced IPV. The influence of traditional gender roles acceptance and decision-making autonomy were examined both as independent variables and in interaction with IPV, to assess their role as potential mediators or moderators. SETTING Chandpur district, Bangladesh. PARTICIPANTS the sample comprised of 426 Bangladeshi women, aged 15-49 years. Postpartum mothers who visited vaccinations centres to receive their childrens vaccinations constitute the sampling frame. RESULTS almost 70% of the women surveyed reported patterns consistent with delayed entry into prenatal care. Accounting for the influence of other covariates, women who experienced physical IPV during pregnancy were 2.61 times more likely (95% CI [1.33, 5.09]) to have delayed entry into prenatal care than their counterparts who did not report physical IPV. Neither sexual nor psychological IPV victimization during pregnancy was linked with late entry into prenatal care. Both gender role attitudes and levels of autonomy mediate the effect of IPV on prenatal care. KEY CONCLUSIONS the results suggest that the high rates of IPV in Bangladesh have effects that can compromise womens health seeking behaviour during pregnancy, putting them and their developing fetus at risk. Specifically, Bangladeshi women who experience physical IPV during pregnancy are more likely to delay or forgo prenatal care, an effect that is further magnified by cultural ideals that emphasize womens traditional roles and limit their autonomy. IMPLICATIONS FOR PRACTICE this study reinforces the need to detect and assist women suffering IPV, not only to offer them help and support but also to increase entry into prenatal care. Healthcare professionals involved in obstetrics and midwifery need to be aware of the risk factors of IPV during pregnancy and be able to identify women who are at risk for delayed entry into prenatal care.

An enquiry of ‘Every3Days’ a drama-based workshop developing professional collaboration for women experiencing domestic violence during pregnancy in the South East of England

OBJECTIVE this exploratory work examined and assessed the experiences of participants (n=90) using an interactive drama workshop to facilitate the planning and understanding of multiagency working around domestic violence during pregnancy. DESIGN a descriptive research design was utilised to collect data from field observations, participant reflective feedback sheets and semi-structured telephone interviews. PARTICIPANTS participants invited to the workshop originated from a wide range of backgrounds including health and social care, criminal justice and the third sector. All participants were invited to complete the reflective feedback evaluation form. To enhance the comprehensiveness of the enquiry, semi-structured interviews were also conducted with 10 of the participants. FINDINGS shared themes emerging from the data analysis included improved awareness of the consequences of domestic violence; greater understanding of multiple professional roles including the policy context and enhanced skill development. However, participants questioned the extent to which this approach impacted upon longer term practice and policy development. KEY CONCLUSIONS by centring attention on the emic perspective of women themselves, the drama approach developed professionals awareness, relationships, understanding and skills. Nevertheless, drama can be an expensive education tool. It is therefore essential that further research explores the longer term impacts on practice and outcomes for women that include cost-benefit analysis.

Exploring the Prevalence and Correlates Associated With Intimate Partner Violence During Pregnancy in Bangladesh

Intimate partner violence (IPV) during pregnancy is known to have multiple detrimental consequences for the woman and potentially for her unborn child. However, little is known about the nature and extent of IPV during pregnancy, particularly in developing countries, which compromises efforts to address the problem. Relying on population-based data, this article examines the extent, patterns, and correlates associated with physical, sexual, and psychological IPV during pregnancy in Bangladesh. Cross-sectional survey data were collected between October 2015 and January 2016 from 426 new mothers, aged 15 to 49 years, who were in the first 6 months postpartum. IPV was assessed with a validated set of survey items. Multivariate logistic regression analyses were conducted to evaluate correlates associated with different types of IPV. Overall, 66.4% of women experienced any IPV during pregnancy. The prevalence of physical, sexual, and psychological IPV was 35.2%, 18.5%, and 65%, respectively. These forms of IPV often overlap, particularly physical and psychological IPV. Pregnant women who report limited social support and have controlling husbands are at significantly increased risk for all three types of IPV during pregnancy. Women who cling to traditional gender roles and those with low self-esteem exhibit increased risk for physical and psychological IPV during pregnancy. Psychological IPV during pregnancy is also correlated with low decision-making autonomy and childhood exposure to violence. Women whose husband’s demand a dowry at marriage are at increased risk of sexual IPV during pregnancy. Results reinforce the need to conduct routine screening during pregnancy to identify women with a history of IPV and to be able to offer help and support. The findings also reinforce calls for gender equity and women’s equal access to family and social resources thereby increasing women’s social support networks, their self-esteem, and autonomy, and reducing their risk of IPV during pregnancy.

Assessment of the quality and applicability of an e-portfolio capstone assessment item within a bachelor of midwifery program.

Education programs leading to professional licencing need to ensure assessments throughout the program are constructively aligned and mapped to the specific professional expectations. Within the final year of an undergraduate degree, a student is required to transform and prepare for professional practice. Establishing assessment items that are authentic and able to reflect this transformation is a challenge for universities. This paper both describes the considerations around the design of a capstone assessment and evaluates, from an academics perspective, the quality and applicability of an e-portfolio as a capstone assessment item for undergraduate courses leading to a professional qualification. The e-portfolio was seen to meet nine quality indicators for assessment. Academics evaluated the e-portfolio as an authentic assessment item that would engage the students and provide them with a platform for ongoing professional development and lifelong learning. The processes of reflection on strengths, weaknesses, opportunities and threats, comparison of clinical experiences with national statistics, preparation of professional philosophy and development of a curriculum vitae, whilst recognised as comprehensive and challenging were seen as highly valuable to the student transforming into the profession.

Exploring Intimate Partner Violence Before, During, and After Pregnancy in Bangladesh:

Intimate partner violence (IPV) against pregnant or postpartum women is known to have multiple detrimental effects on women and their children. Although results from past research suggest much continuity in trajectories of IPV, it is unclear whether pregnancy interrupts or augments these patterns. Little is known about how physical, sexual, and psychological IPV change and overlap throughout a womans transition to parenthood. Relying on population-based data, this study examines the prevalence, co-occurring nature, and the changing patterns of physical, sexual, and psychological IPV before, during, and after pregnancy in Bangladesh. Cross-sectional survey data were collected between October 2015 and January 2016 in the Chandpur District of Bangladesh from 426 new mothers, aged 15 to 49 years, who were in the first 6 months postpartum. IPV was assessed with a validated set of survey items. The frequencies of different types of IPV victimization according to the period of occurrence were calculated separately and in a cumulative, co-occurring manner. The prevalence of physical IPV before, during, and after pregnancy was 52.8%, 35.2%, and 32.2%, respectively. The comparative figures for psychological IPV were 67.4%, 65%, and 60.8%, and for sexual IPV were 21.1%, 18.5%, and 15.5%, respectively. The results demonstrate a notable continuity in IPV victimization before, during, and after pregnancy. Psychological IPV is the only type to exhibit a significant reduction during and after pregnancy, compared with before pregnancy, but it commonly overlaps with physical IPV, which shows a significant change during pregnancy and little change in the postpartum period. At the same time, pregnancy and childbirth offer little protection against IPV for women in relationships characterized by psychological or sexual victimization, both of which commonly overlap with physical IPV. Results reinforce the need to conduct routine screening during pregnancy to identify women with a history of IPV and to offer necessary help and support.