Title: Domestic violence among serving and ex-serving UK military personnel: prevalence, risk factors, help-seeking behaviour and the response of services.
Funder: Department of Health and Social Care

Abstract: Background: Domestic Violence (DV) is a global public health problem associated with a range of adverse health and social consequences including physical and mental health problems and alcohol misuse and is estimated to cost the UK 16billion per annum. We have already shown that violent behaviour is increased in UK military personnel, both serving and ex-serving, compared to the general UK population. It is not known if this is the case for DV. Studies from America support this hypothesis, but we cannot extrapolate from US data to the UK. This is an important issue for the NHS, which has responsibility for the healthcare of ex-serving personnel and their families, and increasingly those who are still serving. Development of a DV prevention and management programme for this population must be informed by UK research evidence. Aims: To estimate the prevalence of and risk factors for DV perpetration/victimisation among serving/ex-serving UK military personnel. To improve understanding of the impact of military life on the risk of DV perpetration and victimisation and to identify barriers to help-seeking and support. To explore the attitudes and response of the UK Armed Forces to DV perpetration/victimisation. To develop expert consensus on recommendations for changes to policy and practice required for better DV prevention and management for serving/ex-serving UK military personnel to feed into national guidelines. Research questions: What is the prevalence of DV perpetration/victimisation among a representative sample of serving and ex-serving UK military personnel compared to the general UK population and what factors are associated with DV, including socio-demographic/economic factors, military-specific factors such as deployment and combat exposure, mental health and alcohol misuse problems? What are the attitudes of DV perpetrators and victims among serving/ex-serving personnel to help-seeking and what is their perception of support available? How does the UK Armed Forces currently identify and respond to DV and what are the opportunities for/barriers to identifying and managing DV? What changes to policy and practice are required to develop a successful DV prevention and management programme for this population? Plan of investigation: Four modules of research will address each of the four main aims: Module 1: Data from the only longterm study into the health of UK military personnel, which has been collecting data since the beginning of the Iraq war (n>14,000), will be used to estimate the prevalence of and risk factors for self-reported DV perpetration/victimisation in the past year, among serving and ex-serving personnel. Module 2: Qualitative interviews will be conducted among both perpetrators and victims of DV, to explore the impact of military service on their relationship, their attitude to help-seeking for violence within the relationship, services available and barriers to seeking support. Module 3: Qualitative interviews will be conducted with military Commanding Officers and healthcare/welfare staff to explore attitudes to domestic violence within the military and to examine how DV perpetration/victimisation is identified and managed. Module 4: A modified Delphi methodology will be used to develop expert consensus on good practice in the prevention and management of DV among serving and ex-serving UK military personnel. Benefit to patients and the NHS: This research has the potential to reduce the harm resulting from DV to serving and ex-serving military personnel and their families, both perpetrators and victims, and the costs associated with it. The findings from this study will provide the first UK evidence to inform expert consensus on good practice in DV prevention and management in this population and a framework for change in practice and policy will be developed along with educational materials to skill the multiagency workforce in how to identify and manage DV in this population.

Lay abstract: Background: Domestic Violence (DV) is a global public health problem associated with a range of adverse health and social consequences including physical and mental health problems and alcohol misuse. It is estimated to cost the UK 16billion per annum. We have already shown that violent behaviour is increased in UK military personnel, both serving and ex-serving, compared to the general population. It is not known if this is the case for DV. Studies from America support this hypothesis, but we cannot extrapolate from US data to the UK. This is an important issue for the NHS, which has responsibility for the healthcare of ex-serving personnel and their families, and increasingly those who are still serving. Development of a DV prevention and management programme for this population must be informed by UK research evidence. Aims: This study will determine (i)how common DV is (perpetration and victimisation) among serving and ex-serving military personnel, and whether this differs from the prevalence in the general population; (ii)whether factors specific to military life increase the risk of DV, such as being deployed to a conflict zone and exposed to combat trauma; (iii) what perception perpetrators and victims of DV have of the impact that military life has on their relationship, their attitude to seeking help for DV and their perception of support services available; (iv) the attitudes of senior figures in the UK Armed forces to DV and the experiences of health and welfare staff of identifying and managing it. All of this will lead to recommendations for good practice in the prevention and management of DV in this population which will feed into national guidelines.Design and methods: This study will consist of 4 study modules. Module 1 will use data from the only longterm study into the health of UK military personnel, which has been collecting data since the beginning of the Iraq war. New questions about DV have been added to the next round of data collection in 2015, which will allow us to estimate how many in our sample report these behaviours, to compare with studies from the general population which have used similar questions and to look at risk factors for DV in this population. In module 2, a sample of those who have self-reported DV perpetration or victimisation will be interviewed to explore the questions described above. In module 3, a selection of Commanding Officers and health and welfare workers will be interviewed to explore their attitudes to DV within the Armed Forces and their experience of identifying and managing it. The findings will be sent to a group of experts, including service users and families, who will answer questions about key elements of good practice in the prevention and management of DV within this population to achieve group consensus on a set of guidelines. Patient and public involvement: The King's Centre for Military Health research has a long tradition of public and patient involvement and work closely with military and veterans's charities. Several veterans are part of the team. Individuals with experience of providing support to military personnel and their families (NHS, Armed Forces, third sector agencies, criminal justice workers), users and carers recruited from NIHR Military Veterans' Research Steering group, academics and policy makers have been consulted in the development of this proposal and will be invited into a Patient and Public Involvement Group which will help inform the development of the research protocols, procedures and materials and aid dissemination.Dissemination: The findings will be communicated widely through a variety of media (academic papers, presentations, layperson updates in newsletters and websites, social and broadcast media) to ensure optimal accessibility. Public dissemination workshops will be held to discuss the implications. There is a high level of parliamentary interest in this work - so much so that a recent cross-party independent review into ex-serving personnel in the criminal justice system commented on this proposal and concluded that they expected parliament to note and act on whatever findings are reported. Benefit to patients and the NHS:This research has the potential to reduce harm resulting from DV to serving and ex-serving military personnel and their families, both perpetrators and victims, and the costs associated with it. The findings will provide the first UK evidence to inform expert consensus on good practice in DV prevention and management in this population and a framework for change in practice and policy will be developed along with educational materials to skill the multiagency workforce in how to identify and manage DV in this population.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING;2.3 PSYCHOLOGICAL, SOCIAL AND ECONOMIC FACTORS
Health categories: MENTAL HEALTH