Global level Responses to Domestic Violence
Violence as a Public Health Problem
As part of the World Health Assembly, Scotland ratified the World Health Organisation report on Violence and Health (Krug et al., 2002). By ratifying the report the Scottish Minister of Health
acknowledged violence as a public health problem. Ratification also entailed a commitment to develop national efforts to respond to the health needs of women experiencing domestic violence. At the time of this research the WHO report had been launched formally in England and Wales, but not Scotland. No public health prevention plan was in development. The regional health service were, however, preparing a
‘gender and health paper’ in a bid to encourage the Executive Health Department to respond.
National level Responses to Domestic Violence
National Health Service (NHS) Guidelines
In 2003 the Executive Minister for Health released "Responding to Domestic Abuse in NHS Scotland - Guidance for Healthcare Workers". This document provided guidance for National Health Service (NHS) workers by the Scottish Executive Health Department. The guidance utilises the Executive
definition and policy on domestic abuse, and offers clarification of the role of the NHS in responding to this problem. The report advises NHS workers of the health effects of domestic abuse and the signs they should be aware of which may indicate someone in their care is experiencing abuse. The 2004 Executive training strategy notes that amongst health care workers there is a “personal reluctance to encroach on what is often perceived as private problems” (p.16). Workers are advised on strategies to help them raise the subject of domestic abuse in the clinical setting and offered guidance on supporting and advising women dealing with abuse. A list of available community supports for women experiencing domestic abuse are included in the report for the use of workers. The report outlines the responsibilities of the NHS management structures to help and support health care workers “to ensure that they are able to respond effectively to anyone
experiencing domestic abuse”. Management are required to ‘produce local templates for the
account when doing so, including staff education and training needs.
National Domestic Abuse Training Strategy
The 2004 Executive training strategy outlines issues specific to building effective responses within health care settings. The report emphasises the crucial role of health services, stating that “whilst many women experiencing abuse may use other services, the role of the Health Service is pivotal since virtually all women will at some point interact with health services, either on their own or their children’s behalf”
(p.16, 2004). The training strategy recommends that NHS managers focus their initial efforts to develop adequate responses to domestic abuse on the services most often used by women experiencing abuse, suggesting “the Mental Health, Primary Care, Maternity and Accident & Emergency services” as priorities,
“In view of the prevalence of abuse amongst women” using these services (p.16, 2004). NHS staff are said to need training that offers basic awareness-raising seminars and more skills-based interventions.
The training guidelines also clearly state the need for staff training to include a focus on perpetrators of abuse and the role of the health service in responding to them. The strategy advises “training should cover all levels of staff in debunking myths about the nature of abusers and the reasons they abuse”. The strategy suggests that General Practitioners (physicians) are:
“likely to be the first contact point for the (admittedly small) number of perpetrators looking for help”. A perpetrator is likely to present with problems of depression, anxiety, alcohol, anger problems, etc. GPs and other staff need to have the insight to look beyond this and see the knock-on problems in relation to women and children, as well as to offer the perpetrator access to a service which might stop his abuse.”
(p.17, 2004)
Indirect Regional level Responses to Domestic Violence
Public Health Department
During interview, a lead Public Health planner with the Newville Health Board clarified that their department was less concerned with service provision and more focussed on prevention efforts to promote good health. The department has to follow nationally set public health targets to reduce inequalities in health, with a specific focus on improving nutrition, community safety, physical activity and heart health.
They did not view domestic abuse as the public health department’s remit. They suggested rather that it
was more the remit of the women’s health team. Within the health board domestic abuse is seen as a women’s problem as opposed to a societal problem. In practice this would mean that the region were not engaging with domestic violence as a preventable public health problem at that time. The representative of the women’s health team was not available for interview at the time of the evaluation and therefore the full health board perspective and practice relating to domestic abuse cannot be commented upon.
Interestingly the public health team part finance the local community Newville domestic abuse project. The health worker explained this was due to the projects “thoughtful, well-respected and
participatory approach to working with local community members”. The funding of the project reflects the public health department’s objective of working in partnership with local communities to create structural change in order to improve the health of the population.
Direct Regional level Responses to Domestic Violence
Dedicated Midwifery Service
The NHS department of midwifery in Newville has allocated funds for employment of midwife posts dedicated to improving midwife service practice in responding to domestic abuse. This important service is able to provide a response to a specific sub-group of women utilising the health service, namely women of childbearing age who are expecting and go on to deliver babies.
The lead midwife said that the rationale for the service is to counter the impact domestic abuse has on the physical and mental health of women and children, including those yet to be born. They explained that babies have been born with fractures that may not have been a result of delivery but as a result of physical assault to their mother when in the womb. The services perspective on domestic violence is reported as ‘gendered’, viewing domestic abuse as a problem of male abuse of power and control. The service prefer to use the term ‘abuse’ over ‘violence’ in recognition of the emotional, sexual and financial abuse that women may suffer, with or without suffering physical abuse.
When the service was first established, they sent out a questionnaire to over 600 nurses, midwifery and gynaecology staff. Their response rate was 59%, of whom most reported having a role in responding to domestic abuse, seen as a supportive role. Their preliminary study of health records suggested that some
of their colleagues were “clueless” about domestic abuse, or “colluding” with silencing of the abuse. As examples they shared statements recorded in patient files after routine vaginal examinations. Some records simply state “difficult vaginal examinations” with no indication that inquiries were made as to what made the exam difficult. Other records showed even less helpful responses such as “un-co-operative patient”,
“abusive patient”, or simply “junky”, a colloquial term for a drug addict.
These dedicated midwives support the wider community of midwives, helping them to identify domestic abuse and respond appropriately when it is reported, disclosed or discovered. They offer staff training and ensure useful literature and resource information is available in all midwife work settings. The worker interviewed reported that since establishment of the dedicated posts, and staff training, disclosures of abuse have ‘rocketed’. They are finding that the most important thing women appreciate during disclosure is being listened to, and believed. Midwives are encouraged to inquire how they can best support each woman that discloses abuse.
Indirect Local Community level Responses to Domestic Violence
Mental Health
Support for those dealing with psychological and mental health problems is available in the local community through referrals to the community mental health team. These services have counsellors, psychologists, psychiatrists and community psychiatric nurses (CPN’s) available for consultation. The mental health teams are understaffed throughout the region, making it very difficult to obtain a referral or to be offered an appointment. When appointments are offered, they are usually for several months in the future. Once someone is actively attending the mental health service they can receive more immediate support, especially from CPN’s, although the entire system is appointment based with no out of hours or crisis provision. The Newville Project has received many referrals from the local mental hea lth service.
They explain that the service ‘doesn’t know what to do with women experiencing abuse’, and have found this to be due to the service having no operational diagnosis for abuse as a psychological or psychiatric health problem. The project advised that they were continuing to work with the service in recognition of how essential the service could be to women recovering emotionally from abuse. One of the support-action
group members reported that over all the years of abuse she endured that the emotional abuse was always harder to bare than the physical. She called it ‘mental cruelty’, giving an example of her husband typically saying things like ‘when you go out make sure you walk under a bus’. For this lady the support of ‘her’
CPN was said to be invaluable in her rebuilding her mental health after years of emotional and physical abuse. The project continue to accept referrals from the mental health team while endeavouring to educate them and help them develop more appropriate responses for women suffering emotionally and
psychologically from abuse.
Direct Local Community level Responses to Domestic Violence
Local Midwife
One of the dedicated domestic abuse service midwives regularly attends the local domestic violence forum, offering updates on policy and practices and seeking input from the group on how best to respond to women in the health setting who may be suffering abuse. This worker can then serve as a direct contact for other local agencies when they come into contact with pregnant women seeking support for abuse.
Art Therapy with Children
The Newville project and local support-action group used part of their funding to pay for two local childcare workers to be trained in art therapy. They did this in a bid to create a resource for the children of local women experiencing abuse. They hope that the art therapy offered to children can help them work through their experiences of witnessing and/or experiencing abuse and minimise their development of violent behaviour within their peer and sibling relationships.