Identifying patients experiencing domestic violence and abuse in general practice

Dr Vasumathy Sivarajasingam describes a pilot project in her practice that used a two-question screening tool to identify, and then offer support to, patients experiencing domestic violence during the pandemic.

(Photo: demaerre/Getty Images)
(Photo: demaerre/Getty Images)

The Crime Survey for England and Wales for the year ending March 2020, estimated 2.3m people aged 16 to 74 years experienced domestic abuse (1.6m women and 757,000 men).1

On average two women are killed by their partner or ex-partner every week in England and Wales.2

A victim will experience abuse on average for three years before getting effective help and will visit their GP 4.3 times.3

The National Domestic Abuse Helpline reported a 50% increase in calls compared to pre-COVID-19, along with a 400 % increase in visits to its website.4 More than 25 organisations helping those suffering domestic violence have reported an increase in their caseload since the start of the pandemic.

The pandemic also means that more people at risk from abuse are forced to stay indoors with their abusers, while social restrictions and stay-at-home mandates will also amplify pre-existing mental health conditions (eg depression, anxiety) and psychosomatic distress reactions (eg insomnia, OCD).5 There are concerns of increased DVA especially unreported cases.6

The role of primary care

General practice has an important role because we deal with injuries caused by DVA. We are often the victim’s first or only contact, providing a lifeline to safety. DVA impacts on both mental and physical health and has ramifications throughout the family.

However, the usual channels of support are now jeopardised by lockdowns and social distancing and those suffering domestic abuse need to find alternative means of support and safety.

An additional challenge is how we can best identify, approach and support patients given our new ways of working. We now deal with the majority of appointments via video, email and telephone consultations - physical contact with these patients is scarce during the pandemic. With remote consultations it is hard to assess who is on the other side and many people experiencing DVA may find it difficult to say what is happening to them when they are actually speaking from their home rather than a neutral place like the surgery.

Screening tools

There are a number of assessment tools and guidance to help promote recognition of, and offer support to, those experiencing DVA.7

Clinicians tend to be reticent about asking about domestic violence directly, but surveys have shown that women experiencing abuse consider it appropriate that doctors and nurses ask direct questions about the issue.8 However, many clinicians do not want to open Pandora’s Box and then not be able to deal with what comes out of it.

Evidence suggests that routine or universal healthcare screening for DVA improves levels of victim identification in primary care.9,10,11 No difference in impact has been detected according to the screening technique used (health professional/face-to-face or written/computer-based screening). Many studies have found that lack of time can be a barrier to screening and therefore self-administered screening could overcome this.9

In our practice

We decided to conduct a pilot study to see if a screening tool would help us identify male and female patients aged >18 years in our practice experiencing DVA. Given the time constraints of a busy practice, we wanted a screening test which is simple to use, short, safe, precise and validated, which is why we decided to use the Women Abuse Screening Tool-short (WAST-short).

The WAST-short was developed in the US and is used by family physicians during routine office visits or well-woman examinations to identify and assess women patients experiencing emotional and/or physical abuse by their partner.11,12,13

It contains the first two questions of the full WAST tool:

1. In general, how would you describe your relationship?
a. No tension
b. Some tension
c.A lot of tension

2. Do you and your partner work out arguments with...
a. No difficulty
b. Some difficulty
c. Great difficulty?

If a patient answers ‘c’ to these two questions, the physician can then use the remaining WAST questions,14 or other appropriate questions to elicit more information about their experience of abuse. 

Research found that 100% of family physicians reported feeling comfortable asking WAST-short questions and 91% of women reported feeling comfortable being asked the questions.11,13 For self-administered DVA screening, the WAST-Short is shown to be the most cost effective tool.9 WAST–Short has a sensitivity of 91.7% and a specificity of 100%, validated by both the CDC and the NIH.12

Our study

The pilot study was conducted on patients contacting clinicians at the surgery over an eight-week period.

Patients engaging with the practice (whether face-to-face, by video or telephone) were given the opportunity to respond to the two-question screening tool. Even though WAST was originally designed for women, we used this tool on our male patients as we felt the questions were simple, non-gender specific and captured what we needed to know to improve identification of DVA.

The response was recorded on a SystmOne workflow template. Those patients who answered ‘c’ to both questions were asked additional questions and offered further support as appropriate. Patients were given the choice of receiving a text with useful links to information about DVA support.

The results

Data were collected from 150 patients answering the two questions. Only one patient declined to answer the questions.

The age range was 21–88 years, 24% males (n =36) and 76% females (n = 114). Of these patients, five were identified as being exposed to domestic abuse (3 female, 2 male).

Two patients reported having a lot of tension in their relationship and great difficulty sorting any arguments. Three patients reported as having some tension in their relationship and great difficulty sorting any arguments. Patients who admitted to have being exposed to abuse, were given additional support.

Of all the patients who answered the questionnaire, 38% (n= 57) were happy to receive information about DVA via SMS.

What next?

We hope to continue the pilot study to gather further data from a wider population.

Our experiences highlighted that a short, simple, non-threatening questionnaire can be used in a busy general practice to identify patients exposed to DVA.

We found that the WAST-short screening tool was acceptable to our patients. Patients were also willing to receive information on DVA support via SMS and this information can easily be shared with others who might be suffering DVA.

Along with identifying patients experiencing DVA the project has also raised awareness of the issue, which has helped to encourage people to talk openly about their experiences.

We strongly believe that as front line workers, we need to be proactive in reaching out to our patients experiencing DVA. Evidence suggests higher rates of disclosure may be obtained using computer-assisted, self-administered screening, however but patient access to this technology may be limited.5

Our vision now is to develop a digital tool using the WAST-short questionnaire that can be sent to all our patients aged 18 years or above electronically as a blanket screening, which will further help towards analysing and identifying DVA victims.

  • Dr Sivarajasingamis a GP partner at Hillview Surgery, Perivale, West London

References

  1. Office for National Statistics.. Domestic abuse in England and Wales overview: November 2020 
  2. Office for National Statistics. Domestic abuse in England and Wales: year ending March 2017
  3. Safe Lives Pathfinder project. Guidance for general practitioners responding to domestic abuse.
  4. Refuge response to Home Affairs Select Committee report on domestic abuse during Covid-19.
  5. Emezue, C. Digital or Digitally Delivered Responses to Domestic and Intimate Partner Violence During COVID-19. JMIR Public Health Surveill 2020; 6(3): e19831
  6. Talking Parents. Why domestic violence goes unreported. July 2019.
  7. Royal College of Nursing list of resources; RCGP list of resources
  8. Harding, M. Domestic violence. Patient.info 2 April 2014
  9. Chen, P-H, Rovi SR, Johnson MS. Costs Effectiveness of Domestic Violence Screening in Primary Care Settings: A Comparison of 3 Methods. J Comm Med Health Edu 2013; 3:253. doi: 10.4172/2161-0711.1000253
  10. College of Policing. Healthcare screening for domestic abuse. November 2017 
  11. Brown JB, Lent B, Schmidt G, Sas G. Application of the Woman Abuse Screening Tool (WAST) and WAST-short in the family practice setting J Fam Pract 2000; 49(10): 896-903.
  12. Hall, Michael J., Intimate Partner Violence: Updated Screening Tool and Approach to Screen Positive Patients. 2018. Family Medicine Clerkship Student Projects. 342. 
  13. Brow, J,  Lent B, Brett-MacLean P,  Sas G, Pederson L.  Development of the Woman Abuse Screening Tool for use in family practice. Family Medicine 1996; 28. 422-8.  
  14. WAST Screen for Intimate Partner Violence

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