stimulating primary care for family violence ......stimulating primary care for family violence :...

Stimulating Primary Care for family Violence : interdisciplinary

coordination needed Pas Leo,

Kelly Blank, P Franck &

J Kenkre,C Fernandez Alonso, N Kopcavar, Hagit Dascal Weichendler, K

Hegarty ….

Contact : [email protected]

mailto:[email protected]

WONCA Special Interest Group Family Violence

• IPV estimated by WHO to be 1 on 3 women 37% in Africa/South East Asia to 24% in Europe and Australia.

The Special Interest Group wants to join expertise from relevant other WONCA Working groups and other primary care networks to develop an collaborative strategy in the fight against Family Violence. Already involved :

WONCA WORKING PARTY WOMEN AND FAMILY MEDECINE EUROPREV : PREVENTION AND DISCLOSURE VASCO DA GAMMA AND YOUNG DOCTORS MOUEVEMENT : TRAINING AFRIWON : COMMUNITY APPOACH WONCA RURAL WORKING PARTY : RURAL ARREAS EQUIP : SAFETY EGPRN : RESEARCH STARTGEY

Contact : [email protected]




Capacity building in European countries

Strengthening the support for victims of gender-based violence (GBV)

Focusing on intimate partner violence in health settings.

IMPLEMENT – Specialized Support for Victims of Violence in Health Care Systems across Europe

JUST/2014/DAP/5361

1. How should PHCP be involved against family violence?

2. How can this be promoted and supported effectively ?

After this meeting : • Further policy and action development • Collaboration on training initiatives

Questions workshop

Outline

1. How to deal with IPV/GBV/FV

– Tasks of PHC Professionals

– Models to organise care

2. Supporting PHCP role

– Training

– Systems’ support

3. Discussion

– How to adapt to settings and professional facilities ?

– Networks collaboration : strategy development

1. INVOLVEMENT OF PHCP

No professional can deal alone with family violence

SASA Project Uganda Abramsky T et AL. BMC Medical 2014,12:122

WONCA AFRICA 2015 :

• Firm resolution that GP/FM can be role model

• GP should create a longstanding trusted relationship with the community

• Involve positively community leaders

• Document negative consequences

• Of any kind of violence and agressive acts

• Combat underlying problems (alcohol,views…)

• Feelings of lack of power : action plan needed

IPossible role for voluntary workers Joyce Kenkre

• All UK schemes voluntary child care,

• 18 months data 2011-2

• 33,925 families in the UK

• 76,031 children

• Support by 15,000 volunteers

• helping families who have children aged under 5 years

© University of South Wales

Circumstances on Referral

• 11,644 (34%) Living alone: 379 fathers

• 8668 (26%) Mental Health

• 5053 (15%) Postnatal depression

• 4391 (13%) Domestic abuse

• 1702 (5%) Learning disabilities

• 1390 (4%) Substance abuse

• 1146 (3%) Teenage pregnancy

• 365 (1%) Interpreter needed


Needs of families with high risk domestic abuse versus those not at risk of DA at referral

• Stress through conflict in the family ↑32%

• Coping with self esteem ↑ 19%

• Coping with feeling isolated ↑ 12%

• Managing the household budget ↑12%


Domains - Journey of Change


Initial visit Review visit End visit

0

0,5

1

1,5

2

2,5

3

3,5

4

4,5

5

Parenting skills

Parental well being

Children's well being

Family management

CLINICAL APPROACH

• WHO 2013 guideline : • http://apps.who.int/iris/bitstream/10665/85240/1/9789241548595_eng.pdf

Special forms of violence coming to Europe…

Form of violence Examples of countries

Bride kidnapping other forms of forced marriage

Kazakhstan, Kyrgyzstan, Turkey

Early/child marriage Observed in most countries of the region

Gender-biased sex-selection in favour of boys

Albania, Armenia, Azerbaijan, Georgia

Ill—treatment and torture in detention

Observed in many countries of the region

Killings in the name of honour Albania, Turkey

Bride kidnapping other forms of forced marriage

Kazakhstan, Kyrgyzstan, Turkey

Early/child marriage Observed in many Asian and African countries

H2

17

ASSISTED DISCLOSURE NEED

1. Health care professionals (HCP) need to (WHO 2013) :

– Ask about FV to promote disclosing

– Assess immediate risks (IPV)

– Assure safety

2. Screening controversial : casefinding unless high risk

3. Detection : 4-10 x if trained, referral : 1/6 (IRIS)

ADAPT TO DIFFERENCES IN PREVALENCE AND CASE MIX (somatic/mental/social lifedomains)

TOP OF ICEBERG : LAW ENFORCEMENT

MIDDLE :

SPECIAL CARE PROVISION

BOTTOM :

PRIMARY HEALTH CARE & SOCIAL WELFARE

AFTER THE DISCLOSURE CARE PATHWAY THE APPROACH SHOULD

1. be adapted to local settings 2. to be coordinated between professionals

CARE PHCP IN LOCAL COMMUNITY

EMERGENCY OR SUPPORT SETTING

MENTAL HEALTH ORIENTED TEAM

CONTACTS

REGULAR EMERGENCIES ONLY

AT INTAKE AND PLANNED FU

ASK + + ++

ASSESS ? ++ ++

AGREE REFER REFER ++

ASSIST + FU ? REFER BUT CHECK MANAGE/REFER BACK/ REFER

1. ASK ANXIETY TO GO HOME + WHY ? 2. ASSESS TYPOLOGY VIOLENCE & NEGLECT

EVOLUTION time/severity IDEAS CONCERNS EXPECTATIONS SAFETY PHYS SEKS VIOLENCE CHILDREN TREATS / WEAPONS CONTEXT pregnancy/drugs DEPENDENCY emotional/financial/cultural

3. ADVICE ACKNOWLEGDE FACILITIES MOTIVATE REFFERAL (if facilities available)

COMPLEXE EXPLORATION NEED: Emotions , Behavior , Context

BASIC STRATEGY IMPLEMENT

o First-line support o immediate support o support and validation o ‘psychological first aid’

o Women-centered care o Validation o Practical care, non-intrusive o Sensitive and patient o Information-giving o Increase safety and sense of control o Confidentiality and privacy o Social support o Effective referrals

(WHO, “Responding to Intimate Partner Violence and Sexual Violence Against Women” (2013), p. vii.)

(UNFPA-WAVE, p. 74)


JUST/2014/DAP/5361

Services which women survivors contact for help

Service Partner Physical Violence

Partner Sexual Violence

Non-Partner Physical Violence

Non-Partner Sexual Violence

Police 14% 15% 13% 14%

Hospital 11% 12% 9% 12%

Doctor or healthcare institution

15% 22% 10% 16%

Women‘s Shelter 3% 6% (0) (1)

Victim Support Organization

4% 4% 1% 4%

Women who contacted organizations or services after serious incidents of violence since the age of 15 (EU28):

(FRA, Violence Against Women, p. 65)


JUST/2014/DAP/5361

A stepped collaborative care pathway and shared decisionmaking rules

(including sharing information with other providers or lawenforcement)

should be agreed upon

when/before embarking in an active disclosure and referral strategy

MODEL A. DUTCH REPORTING CODE Domestic Violence or child abuse

1. Describe signals ASK 2. Concert with others in own setting DISCUSS 3. Consult advisory- or refer center CONSULT 4. Discuss with client AGREE 5. Weighing violence risk of action ASSESS 6. Decide to assist or report ASSIST REPORT ASSURE FU

MODEL B. Maracs ‘MultiAgency Risk Assessment Comittees’

• Referal of high risk domestic abuse victims

• by care providers or police

• Based on common assessment tool

• Information shared between local agencies

• Ensuring voice of the victim is heard

• Risk focused

• Co-ordinated safety plan made


Model C. FAMILY JUSTICE CENTER

“COMPLEX CASES ARE NOT NECESSARILY HIGH RISK SITUATIONS AND MAY BENEFIT FROM

DIRECT COLLABORATIVE APPROACHES !”

Results

• Long term recidivism ?

• Risk factors decrease

• Protection factors increase

• Better information, more insight in anamneses

• Works on a larger range of life-domains

• Works with entire family

• Perpetrator care included

• More specific orientation, more “tailor-made-work”

• Better feedback

• More continuity in guidance, less gaps

2. PROMOTING PHC P ROLES

Supportive models

Training

• Monitoring and research

Training and

support

+

referral

pathways

including

safeguarding

children and

adults

+

Medical record

prompts

+

Recording and

flagging

system

+

Advocate

educator

+

Practice

champion

Health

education

material

+

Clinical

enquiry

+

Validation

+

Documentation

+

Immediate risk

check and

safety

assessment

Identification

+

Referral

Advocacy

Emotional

&

Practical

support

Identification and referral to Improve Safety G Feder Bristol University (2012)

WHO 2013 review on training

• Most programs oriented to identification

• Most show some increase in knowlegde

• Training in adequate referral is essential

• Interactive methods show changes in identification, attitudes and behavior of PHP

• Simulations, role play and multimedia use

• Training may need to be accompanied by changes in systems of care and referral

General review on training methods Ester Cornelis, Kristof Hillemans, Leo Pas

(Domus Medica report 2007)

• Combination different methodologies superior

• Facilitators in practice most effective

• Individual training supperior to group approach

• Experience based best

• Interactive any way

• Monitoring needed with feedback

GBV advocate I. victim advocacy

o offers emotional and practical support to victims

o provides choices and empowers clients

o patient-led: flexible according to woman’s situation,pace,readiness to change and goals

o offers referrals to wide range of services across all levels of risk

o offers long-term support (rather than short-term crisis intervention)

o provides advocacy for those that may not otherwise access support


JUST/2014/DAP/5361

GBV advocate II. Practice support

o collaborates with ‘clinical lead’ to organise training for health care professionals

o collects patient and practice data

o provides case updates to health care professionals

o ongoing support to clinical team


JUST/2014/DAP/5361

IMPLEMENT SUPPORT Role of clinical lead

o support and provide training for health team on understanding and responding to GBV

o encourage health team to identify GBV and to effectively respond, record, and assess

immediate risk and refer

o provide peer support and maintain effective relationship with health team and GBV

advocate

Role of GBV advocate

o support and provide training for health team on understanding and responding to GBV

o encourage health professionals to identify and effectively respond to GBV

o build and maintain effective relationship with health team and clinical lead

o provide information, support and advocacy for women who disclose their past or current

experiences of GBV


JUST/2014/DAP/5361

DAY 2: o Risk Factors o Risk Assessments o Safety Planning o Referral Pathways o Fundamental Reference Sheet o IMPLEMENT REFERRING PROTOCOL

o Presentations o Training Challenges o GBV Advocacy o Self Care participants o Planning Action o Evaluation and Feedback

DAY 1 : o Working Agreements o IMPLEMENT RATIONAL o PARTICIPANTS ROLE o Myths o Definitions VAW o Dynamics of GBV o Identifying GBV o Barriers in the health system

o How to ask about GBV o Undertaking a medical exam o Recording and classifying injuries

train the trainers

TRAINING MANUAL + reference sheets

Minimum requirements when asking: o Protocol or standard procedure o Health care providers are trained on asking and responding to disclosure o Privacy and confidentiality considerations o Aware and knowledgeable or resources and referral system (IMPLEMENT Fundamental Reference Tool)

When is it safe? o Private and confidential space o Woman is alone o For women who are migrants, refugees, or belong to an ethnic minority and do not speak the local language, ensure the presence of a professional interpreter (avoid using family members as interpreters) (IMPLEMENT Fundamental Reference

Tool)


JUST/2014/DAP/5361

Fundamental Reference Sheets How to respond to GBV :

o Red flags associated with GBV

o Examples of questions (direct/indirect)

o “When is it safe to ask about GBV?” diagram

o Elements of ensuring safety and security in the health system

o What should be documented ?

o “Care pathway for GBV” diagram

o Detailed information of designated referral pathway contacts (GBV advocate)


JUST/2014/DAP/5361

Successes

• Improved referral process (IT)

• Improved knowledge of referral process (DE)

• Improved interest in theme of gender-based violence (IT, DE)

• Increase in number of departments involvement (DE)

• Positive interest/reception of theme (IT)

• Surprising positive demographic involvement (DE)

• Change in attitude towards project, more appreciative (RO)

• Involvement of management = strong support and participation (AT, RO, FR, IT)

• Data collection within health record (BG)

• Doctors listening for the first time about GBV (BG)

FEASIBILITY OF SUCH APPROACH

CARMEN FERNADEZ et AL.

Train the trainers in Health Care Centers in Castilla Y Leon

National Gender

Violence

Awareness and

Prevention Plan

DOVE HOMEVISITING PROJECT COMPARING TRAINED HOMEVISITORS’ WITH TABLET ASSISTED APPROACH

Lorraine Bacchus et AL,2015.

• Women and home visitors were supportive of IPV screening and interventions in the home, but it was challenging to see women alone.

• Nurse-patient interaction and trust was at the core of developing positive and therapeutic relationships and was necessary for the home visitor administered and computer tablet method

• Importance of skill building and practice-enabling components of IPV training programmes and use of teaching methods that facilitate experiential learning and reflective practice and feedback.

Opening the Door: Educational Film for Care Providers About Supporting Families Dealing

with Intimate Partner Violence

Based on research data from the DOVE qualitative study and developed in collaboration with the Drama Department and

Media Department at the University of Virginia

https://www.youtube.com/watch?v=fvnYo63gVvQ

https://www.youtube.com/watch?v=fvnYo63gVvQ

Unfpa manual

III. Workshop discussions

ADAPTING STRATEGY TO CARE SITUATION, COUNTRIES & CULTURES

Possibilities :

1.Through your own network or profession ?

2.Transmit potential contacts in your country ?

3.Describe available strategies/pathways locally ?

4.Compare implementation strategies locally ?

1. What tasks can different care professionals realize to combat FV ? 2. How can this be organized in your health care setting and profession? 3. How should this be further supported? Aim : Action plan for further collaborative action (Rio Oct 2016) INDICATE YOUR NEEDS AND IDEAS : • https://fs10.formsite.com/FAMVIOLENCE/PROJECT2020/index.html OR SEND US YOUR CASE STORIES ABOUT FAMILY VIOLENCE : • https://fs10.formsite.com/FAMVIOLENCE/CASESTORIES/index.html

Questions for discussion

https://fs10.formsite.com/FAMVIOLENCE/PROJECT2020/index.html

https://fs10.formsite.com/FAMVIOLENCE/CASESTORIES/index.html

Provisional statements From earlier WONCA discussions Prague, Kuching, Lisboa, Dubrovnic

SIMPLE COUNSELING CAN REDUCE MENTAL HEALTH CONSEQUENCES OF FV AT LEAST

PHCP CAN AND SHOULD PROVIDE ACTIVE LISTENING AND EMPOWERMENT SUPPORT FOR VICTIMS, INCLUDING THEIR CHILDREN

• MORE TRAINING IS NEEDED AND FOLLOWED BY FIELD SUPPORT STRATEGY TO INCREASE DISCLOSURE, COUNSELING AND COLLABORATIVE CARE (VS REFERRAL)

• SUPPORTIVE STRATEGIES AND CLEAR CARE PATHWAYS

– TO BE ADAPTED TO LOCAL HEALTH SERVICE SETTINGS – PRIOR TO LARGE SCALE PROMOTING DISCLOSURE

• SENSITIVITY TO CULTURAL DIFFERENCES AND VALUES IMPORTANT • ELECTRONIC HEALTH CARE FACILITIES CAN BE A POWERFULL ADJUNCTS

• SHARING INFORMATION AND CONFIDENTIALITY TO BE PLANNED THOROUGHLY

Provisional WONCA SIGFV STATEMENT ON FV

1. PHC SHOULD PROMOTE

– PERSONAL ALERTNESS FOR DIFFERENT PRESENTATIONS OF FV – OWN AND PHC AWARENESS FOR ADEQUATE COUNSELING SKILLS – COMMUNITY AWARENESS – POSITIVE INVIOLVEMENT OF COMMUNITY LEADERS – PATHWAYS TO AVAILABLE SOCIAL CARE – LOOK FOR PROVISIONS FOR SAFETY (SHELTERS, LEGAL CHANGES) – PROMOTE NEW SUPPORT (eg. HELPLINE , INCREASE PRACTICE NURSES …?)

2. FIRST AND SECOND LINE COLLABORATION IN RURAL AREAS – TOOLS NEEDED FOR EDUCATION : blended learning programme development – EVALUATION IN RURAL SETTTINGS : difficulties , online helpline ?

3. PHC SHOULD CONSIDER LEAGL ASPECTS & ROLE OF LAW ENFORCEMENT • NO MANDATORY REPORTING (WHO 2013) • HOW TO SHARE INFORMATION IN CARE • PROTOCOLS HOW TO INVOLVE DIFFERENT PROFESSIONALS

Provisional STATEMENT SHARING INFORMATION

• All Health care, social care and mental health care providers should recognise that nobody can provide help for family violence on all needed domains.

• Hence sharing information is essential within limits of professional confidentiality

• Immediate risk estimation is essential at suspicion in any primary health care setting

• Sharing information should first be considered within own service or with referent professional supervisors

• Sharing information only relevant for care by the other professions consulted should always be considered in Multidisciplinary care

• If possibilities to secure assistance and assure safety are exhausted sharing risk estimation with other professions and sectors of care is needed.

• If care provision can not secure security by any other care service involving Lawenforcement is justified

• It should be preferably performed with agreement of client, but not necessarily so in case of vital danger

INVITATION TO COLLABORATE:

• TRAINING STRATEGY 2016 – 2017

UNDERGRADUATE, GRADUATE AND IN PRACTICE TRAINING :

BLENDED LEARNING DEVELOPMENT ONLINE

OPEN SOURCE

ADAPTABLE TO PROFESSIONS AND COUNTRIES

• MENTAL HEALTH AND FAMILY VIOLENCE PROJECT

• RESEARCH STRATEGY DEVELOPMENT – HOW TO ORGANISE COLLABORATION TO MAXIMISE OUTCOME AND AVOID FURTHER HARM

– Adapting and testing training strategies to local settings – PRACTICE TOOLS FOR DISCLOSURE & IMMEDIATE ASSESSMENT

– SUPPORTIVE STRATEGIES DOMESTIC VIOLENCE ADVOCATES IN PHC-settings

HELPLINES ?

SHELTERS ? …

MONITORING ?

PROJECT DEALING WITH THE RELATIONSHIP OF MENTAL HEALTH PROBLEMS AND VIOLENCE IN PRIMARY CARE: SEARCH FOR PARTNERS

Leo Pas, Hagit Dascal, Shelly Rothschild, Carmen Fernandez, Raquel Gomez, Nena Kopcavar, Marouan Zoghbi, Kelsey Hegarty

Research hypotheses :

• There is a strong relation between mental health problems and family violence • A CBT model exploring with empathy emotions and thoughts and challenging

behaviour may be effective to improve outcomes for related mental health and family violence problems

Research questions :

• Effects of blended training strategy on CBT performance of GP/FM students for MH ?

• What are the effects of the proposed model to casefinding and outcomes of family violence ?

Methodology proposed :

• Feasibility study training counselling Mental Health/FV with CBT using: – WEBBASED CASE-VIGNETTES AND SCRIPTS (INCREASING COMPLEXITY INCL FAMILY VIOLENCE) – SKILLS TRAINING EXCERCISES – PRACTICE ASSIGNMENTS and FOLLOW-UP

• Cluster RCT practices with/without vocationally trained students : – DETECTION – COUNSELING PROCESS AND OUTCOME – REFFERRAL

Action plan international collaborative action (Rio Oct 2016)

INDICATE YOUR VIEWS AND NEEDS :


OR SEND US CASE STORIES ABOUT FAMILY VIOLENCE :




PALDIES THANK YOU SO MUCH TEŞEKKÜR EDERIM MUCHAS GRACIAS ΕΥΧΑΡΙΣΤΩ OBRIGADO TACK SÅ MYCKE DANK U WEL TAG MERCI BIEN

CONTACT : [email protected]

stimulating primary care for family violence ......stimulating primary care for family violence :...

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