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Melbourne research Alliance to End Violence against women and their children Submission to the Standing Committee on Health: Inquiry into Chronic Disease Prevention and Management in Primary Health Care August 2015 Kelsey Hegarty ‐ Professor, Co‐chair of Melbourne Research Alliance to End Violence against women and their children, Director of Researching Abuse and Violence in primary care program, The University of Melbourne Cathy Humphreys Professor, Co‐chair of Melbourne Research Alliance to End Violence against women and their children, Social Work, The University of Melbourne Laura Tarzia ‐ Research Fellow, Deputy Lead of Research Abuse and Violence in Primary Care program, The University of Melbourne Jodie Valpied – Senior Research Assistant, Coordinator of Researching Abuse and Violence in Primary Care program, The University of Melbourne Kirsty Forsdike – Senior Research Assistant, Educational Coordinator of Researching Abuse and Violence in Primary Care program, The University of Melbourne Kitty Novy –Recruitment Officer, Researching Abuse and Violence in Primary Care program, The University of Melbourne Inquiry into Chronic Disease Prevention and Management in Primary Health CareSubmission 150 Introduction Family violence damages the social and economic fabric of communities, as well as the mental and physical health of individual women, men, adolescents and children [1, 2].
In Australia’s Personal Safety Survey, one in five women has experienced sexual violence, 17% of women have experienced violence by a partner, and one woman is killed every week by a current or former partner.

The estimated cost of this violence is $13.2 billion p.a, or roughly 1.1% of Australia’s GDP.

The World Health Organization has prioritised preventing and reducing the extensive damage from family violence especially on children, and identified the crucial role of an effective health system [1, 2].
A recent Lancet series about violence against women and girls reported that ‘strengthening of health systems can enable providers to address violence against women, including protocols, capacity building, effective coordination between agencies, and referral networks’ [6].

Further, there is a need to develop health responses that recognise and address perpetrators of family violence and children as victims in their own right [6].
Intimate partner violence and direct child abuse are overlapping in around half of families with, in relation to chronic disease prevention, the Adverse Childhood Experiences study clearly showing the links between chronic disease and family violence [3].

Work by Vic Health has shown that intimate partner violence is estimated to be the leading contributor to death, disability and illness for Victorian women of child bearing age.
In addressing this complex problem, this submission is supported by global, national and state policy directions.

The WHO [4] and Council of Australian Governments have prioritised preventing and responding to the extensive social and health damage from family violence, and identified the crucial role of the healthcare system [4, 5].
Despite, family and domestic violence being more common and more damaging than asthma or diabetes to women’s health, health systems have lagged behind other agencies in responding to this issue [6].

At least 80% of women experiencing abuse seek help at some point from health services, usually general practice.

Abused women use medical services more frequently because of increased rates of emotional health issues and physical health issues.
Estimates are that up to five abused women per week per doctor attend unsuspecting general practitioners with around 12% of women being afraid of their partners in the last 12 months [8].

The RACGP has outlined nine steps to intervention – the 9 Rs [7] based on a recent evidence review.
The recent WHO guidelines for intimate partner violence and sexual violence against women were include the following recommendations: Women centred care for all survivors; Training for all health professionals in first line response; Case finding rather than screening, except in antenatal care; Written information on partner violence in private areas; No mandatory reporting for partner violence; Trauma informed psychological treatments can assist women who have left the relationship; and Mother‐child interventions – pregnant women should be offered empowerment counselling and psychotherapeutic counselling to assist women and their children to heal.
Recommendations The response of health professionals to family violence could be improved by: First line Response and Referral pathways 1.

Develop new GP Medicare item numbers (similar to the Mental Health Care Plan item numbers) to develop family safety plans and follow up for women, men and children Inquiry into Chronic Disease Prevention and Management in Primary Health CareSubmission 150 2. experiencing family violence.
This would allow GPs who have had training in family violence to spend 30 minutes to assist patients on the pathway to safety.

Identified and accredited specialised services (e.g.

social workers and family violence psychologists who have had extra family violence training) could have access to special item numbers for counselling for up to 10 sessions annually.

Some women may meet criteria for mental health care plans but some may not.

3.
3.

A family based safety plan would allow mother child work and group work which have both been found to be the most effective when women and their children are affected by family violence [6].

Men who use violence could use their plan to access accredited behaviour change programs.

4.

Existing Medicare Chronic Disease Management items should be applied systematically to support family violence survivorship care in the community.
This could be done by including family violence workers as part of general practitioners Medicare Team Care Arrangement and General Practice Management Plan so GPs can refer for five sessions; Workforce development 5.

Mandatory training of all health professionals in child safeguarding that includes family violence.

Cardio Pulmonary Resuscitation is the only mandatory training at the moment.
A regular update on family violence tied to registration through Australian Health Practitioner Regulation Agency would ensure a trained work force to provide a WHO first line response.

In the United Kingdom there is mandatory Child and Adult Safeguarding training for all health practitioners; Hospital system reform 6.

Fund co‐ordinators of family violence in all public health services and clinical family violence leads in all state hospitals.

7.
7.

Co locate other services in large maternity hospitals e.g.

legal, housing, finance services; 8.

Ensure hospital environments are private and sensitive to the needs of patients experiencing 9. family violence using trauma informed care principles; Improve databases including hospital and maternal and child health nurse data to be able to identify family violence, including subgroups e.g.

Aboriginal and Torres Strait Islander people, LGBTI, CALD, disability.
Evidence to support this submission Evidence of best practice informing this submission includes systematic reviews of health care interventions [11] [12] [13] [14] [15] and of qualitative studies [16], consensus guidelines [17], WHO guidelines and clinical handbook, and evaluation of health‐based family violence studies [18] [19] [21].

A recent cluster randomised controlled trial called WEAVE tested the effect of brief counselling by Victorian GPs for women afraid of a partner/ex‐partner.
The study involved 272 women attending 55 GPs.

Half the GPs were trained to provide supportive counselling, and their participating patients were invited to attend this counselling.

The other half received a basic resource kit only, and provided usual care to their participating patients.

Women’s outcomes were measured at baseline, 6 months, 12 months and 24 months.
The study found that trained GPs enquired more about safety of the women and their children, and that depression outcomes were Inquiry into Chronic Disease Prevention and Management in Primary Health CareSubmission 150 better for women invited to attend the counselling.

There were no significant effects on women’s general quality of life, a general mental health score, anxiety or level of comfort to discuss fear of a partner with the GP.
The Weave study showed that GPs could be trained to respond in a supportive, woman‐centred way, and that their knowledge, skills and attitudes were improved.

Furthermore, women fearful of a partner in the last 12 months reported that the GP inquired more about safety of women and children and that they had less depressive symptoms at 12 months, although their quality of life measure was not statistically different between the intervention and comparison groups.
About the submitters Professors Hegarty and Humphreys co chair a new research alliance across The University of Melbourne.The overall aim of the Alliance is to reduce harm and improve the safety, health and wellbeing of women, families and communities through addressing problems of violence against women and children.

Preventing and responding to violence against women and children is not the domain and responsibility of any one discipline.
Intervention in such ‘wicked problems’ which beset our social and cultural lives requires cross‐disciplinary involvement from health, social work, housing, education, law, journalism, gender studies, policy development and criminology.

Professor Kelsey Hegarty leads the Researching Abuse and Violence in primary care program within the Department of General Practice at The University of Melbourne.
The program focuses on early intervention and response to abuse and violence within the primary care setting, and through the use of technology.

Research areas include counseling interventions for women in general practice, online tools for safety in relationships, early intervention with men who use violence in relationships, experiences of unwanted sexual contact in women, and systems models for mental health and sexual violence services.
The utilization of research knowledge to strengthen evidence‐ informed practice is a priority of our work.

References 1.

World Health Organization: Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non‐partner sexual violence.

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Geneva, Switzerland: World Health Organization; 2013.

World Health Organization: Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines.
Geneva, Switzerland: World Health Organization; 2013.

Felliti V, Anda RF, Nordenber D, Williamson D, Spitz AM, Edwards V, Marks J: Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) study.

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American Journal of Preventive Medicine, 1998, 14(4):245‐258.
World Health Organisation (WHO), London School of Hygiene and Tropical Medicine: Preventing intimate partner and sexual violence against women: taking action and generating evidence.

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Geneva, Switzerland: World Health Organisation (WHO); 2010: 94.

Council of Australian Governments: National Plan to Reduce Violence Against Women and their Children.

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Canberra, Australia: Commonwealth of Australia; 2010: 63.
Garcia‐Moreno C, Hegarty K, d'Oliveira A, Koziol‐McLean J, Colombini M, Feder G: The health systems response to violence against women.

The Lancet 2014, 385(9977):1567–1579.

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Melbourne: The Royal Australian College of General Practitioners; 2014.

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Inquiry into Chronic Disease Prevention and Management in Primary Health CareSubmission 150