1. No category

Hawke’s Bay
District Health Board
Child Protection &
Family Violence Intervention
Programme
Dr Russell Wills, Clinical Director Maternal, Child & Youth Continuum
Miranda Ritchie, National VIP Manager for DHBs
Pop: 150,000
<15: 45,000
Births NZDep 910: 50%
% Maori births
50%
Adm: 3,000
Births: 2,200
Paed OP: 5,000,
1,200 NP
Case
• 4 yr old girl seen in clinic recently
• Severe eczema, recurrent infections,
thoracic dermal sinus, many admissions
• FVRQ asked on each admission, always
denied
• All settled!
• Partner in jail, very violent
• DOVE program
FV Epidemiology
• FV is common
• Partner abuse NZ data
– Lifetime incidence: 15-39% of women physically or sexually
abuse
– Preceding 12 months: 15-21% physical or sexual abuse, up to
53% psychological abuse.
– 12 deaths & ~400 women admitted pa 20 to partner abuse
(PA)
• Child abuse & neglect
– Lifetime incidence 4-10% physical abuse & 18% sexual abuse
– 10 deaths & ~200 children admitted pa 20 to child abuse (CA)
• 50% co-occurrence of CA & PA
• Long term negative health impacts from abuse
Screening: Wilson & Jugner
1
10 criteria (after Hall)
1. The condition should be an important public
health problem, judged by potential for health
gain from early diagnosis
Epidemiology of PA2-7
• 11 deaths and 400 hospital admissions a year due
to violence against women in NZ.
• 50% of all homicides of NZ women committed by
current or ex-partner.
• Lifetime incidence: 15-35% of women hit or forced
to have sex vs 7% of men.
• Previous 12 months: 15-21% physical or sexual
abuse and up to 53% psychological abuse.
• Economic cost at least NZ$1.2bn (up to $5.3bn).
The Hitting Home Survey8
• Nationally representative telephone survey of
2000 NZ men, NZ Dept of Justice in 1994.
• At least one act of physical violence against
current partner:
– past year 21%,
– lifetime 35%.
• Psychological abuse
– past year 53%,
– lifetime rate 62%.
Impact of PA on women
• Use of primary care twice that of non-victims and
costs 2.5 times greater9
• PA in pregnancy associated with lower
birthweight, poor maternal weight gain,
infections, anaemia, smoking, drug and alcohol
use10.
• High use of health care persists over time11
• Battered women present to EDs 3 times as often
as controls.
• Present more often not only with trauma, but
with nearly all conditions12.
Impact of PA on child witnesses
• Co-occurrence of PA and child physical abuse
30-60%, increases with frequency and severity
of violence13. Both parents may physically abuse
the child14,15
• Mothers ill or injured, pre-occupied with survival,
PTSD, depressed, alcohol use, decreased
empathy and sensitivity to child’s needs16,
multiple moves, children emotionally and
physically deprived
• Children nearly always aware of parents’
violence, usually present in same room for at
least one episode17.
Impact of PA on child witnesses
• Infants: PTSD, esp if younger, PA frequent
and in close proximity, distressed, irritable,
hiding, shaking, stuttering, developmental
regression16,17
• School age: Low self-esteem, self-blame, poor
concentration, anxious, depressed,
psychosomatic illnesses, grades < ability,
unable to participate in normal school and
social activities, poor attendance, lonely, shy,
isolated, bully, aggressive to peers16,17,18,19
Impact of PA on child witnesses
• Adolescents: early dropout, drug & alcohol
use, delinquency, run away16,17,18,19
• Adult: perpetrator or victim of PA15,poor
psychological adjustment, poor adult
relationships18, 19.
Screening criteria cont.
2. There should be an accepted treatment
or other beneficial intervention for
patients with recognised or occult
disease
3. Treatment at the early, latent, or presymptomatic phase should favourably
influence prognosis, or improve outcome
for the family as a whole
Benefit from early diagnosis?
Two RCTs:
•
•
Screening: in AN clinic→↓ threats of violence (35
→27) and mean physical violence scores (45→35)
over 18 mo, p<.01. Unlimited access to
counseling vs brief information NS20
Intervention: Advocacy service 10wks, 4-6 h/wk
for women in refuges vs no additional
intervention, followed to 2 years (95% retention).
Groups diverged, converged when support
removed, then diverged again at 18-24 months.
QOL, use of social supports and depression most
affected. Median time to first re-abuse 3 vs 9
months; not re-experienced violence at 2 years
24% vs 11% 21.
Benefit from early diagnosis?
Does screening improve outcomes? Case series
with repeated measures:
• AN clinic: Improved adoption of safety
behaviours22
• ED: use of refuge (11→28% p=.003), shelterbased counseling (1→15% p<.001). Repeat ED
visits but NS23
• Hospitals: staff awareness, referrals to refuge
(15→134), patients recall asked, saw FV info,
aware of hospital’s concern about FV, satisfaction with efforts to address FV all
p<.000124,25.
Benefit from early diagnosis?
Patient outcomes notoriously difficult to
demonstrate due to
• very high mobility
• risk to woman/mother of participation in
evaluation/ research
• multiple & varied outcomes not captured
by quantitative methods eg improved
knowledge, practical support (eg child
care), reduced isolation, return to work,
self-esteem.
Screening criteria cont.
4. Suitable test or examination: it should be
simple, valid, reasonably priced, repeatable
in different trials or circumstances, sensitive
and specific; acceptable to the majority of
the population
• 3 simple questions26,27
• Detection rises from near zero to
prevalence close to that expected of
population28,29,30,31,32
• Patients do not mind being asked32,33
Screening criteria cont.
5. There should be an agreed definition of
what is meant by a case and also which
other conditions are likely to be detected
by the screening program and whether
their detection will be an advantage or a
disadvantage
• definitions are accepted34
• More historic than current abuse
detected28,29
• May increase detection of child abuse24.
Screening criteria cont.
6. Facilities for diagnosis and treatment
should be available and shown to be
working effectively for classic cases of the
condition
•
Our own counseling and support
– Improved health outcomes
•
Women’s Refuges
– Improved health outcomes in literature
– National standards of training
•
National Network of Stopping Violence Services
– National standards, evaluated
– Men’s and women’s courses
Screening criteria cont.
7. The cost of screening should be
economically balanced in relation to
expenditure on the care and treatment of
persons with the disorder and to medical
care as a whole
• Brief questions take very little time
• Risk assessment and counseling not >
15 minutes
• May reduce ED and other medical
attendances.
Screening criteria cont.
8. There should be a latent or early
symptomatic stage and extent to which
this can be recognised by parents and
professionals should be known
• Latent phase: women are aware but do
not disclose to health professionals,
unless asked25
Screening criteria cont.
9. The natural history of the condition and of
conditions that may mimic it should be
understood
• Natural history understood: PA continues,
tends to increase, high use of health
facilities continues for at least 5 years11.
Other criteria and justifications
10. Case finding may need to be a continuous
process and not a once and for all event,
but there should be explicit justification for
repeated screening procedures or stages.
•
•
•
•
May not disclose at first encounter
Repeated questioning associated with improved
safety over time1,21,22
Signs & symptoms or high-risk screening alone
does not ↑ identification35,36,37
More rapid acquisition of confidence in asking the
questions
Ethical principles38
• Beneficence: duty to diagnose and treat is greater
than simply addressing physical injury or disease;
must also address the cause because failure to
do so is likely to lead to further injury
• Non-malfeasance: duty to do no harm.
Misdiagnosis leads to treatment that may do more
harm than good, eg prescription of analgesic/
sedative may lead to:
– overdose35
– ↑ vulnerability to injury by reducing ability to protect
herself39
– increased helplessness and entrapment40.
Treat the whole person
Summary: screening
Good evidence that
• Important health problem, that we frequently
miss
• Early diagnosis improves outcomes
• Direct question acceptable, improves rates of
detection
• Resource implications not great, if staff welltrained
• High-risk screening does not improve
identification
And: accurate diagnosis and effective treatment
sometimes requires asking difficult questions
Why Hawke’s Bay?
Influenced by 3 critical factors
1. Sentinel event that resulted in
•
•
•
A child’s death
A government enquiry
Required service integration between Ministries of Health,
Justice & Social Development
2. Health Board’s senior management commitment to
address recommendations on
•
•
Child abuse AND partner abuse
Improved clinical practice
3. Nurse-led initiative in Emergency Department to
establish routine questioning for partner abuse
MoH FVIG: C & PA
• FV in NZ Health Strategy
• Guidelines recommend;
– Routine questioning of women for partner abuse ≥16 years
– Questioning children (+ men) on suspicion of abuse
• Brief intervention includes:
– Identify abuse
– Acknowledge disclosure,
provide emotional support
– Assess risk (Dual risk
assessment)
– Safety plan and refer
– Documentation
– Referral to community
agencies
Changing practice requires a
systems approach
Barriers & enablers
Organisational
Organisational
Enablers
Barriers
Notices
& prompts
Sense of imposed change
Increase management support
Insufficient management
Increase resources, staffing
support
Lack of time, Nature of patients, Lack of Referrals to support staff, feedback
Use vacant single rooms
privacy, Lack of JMO support
Mandatory training for all staff
Delays in Implementation
Policy, resources, supervision
Documentation, Resources
Clinical
Documentation amendments
Language & cultural issues
Use of support & resource staff
Lack of Feedback
ABUSED
Interpreter for language barriers
PERSON
Personal Enablers
Personal Barriers
Determination, commitment
Level of comfort
Staff
Training & case presentations
Fear of the ‘yes’ response
Developing
own questioning manner
Forgetting to routine question (RQ)
Informing shift coordinator of disclosure
Personal reluctance to RQ
Awareness of abuse in society
Perception of not needing to RQ
Initiating supervision process
Requiring a rapport before RQ
Positive feedback from women
Frustration with outcome
Create opportunities to ask
Delaying questioning =>
Empowerment
Lost opportunity
Pride in the intervention
Collaboration is the key
You don’t have to do it all yourself.
Managers
Women’s Refuge
& DOVE HB
Coordinators
FVI & CPP
Paediatricians
Steering
Group
Ministry of
Health
Clinicians
Police & CYFS
Continuum of level of comfort
with routine questioning for
partner abuse
Rate of RQ for PA
Routine
questioning
occurring
N o routine
questioning
occurring
O nly ask
w om en if a
suspicion of
abuse exists
Low
Ask w om en if
circum stances
allow
Seek out
opportunities
to ask all
w om en
Level of com fort w ith routine questioning
(R Q) for partner abuse (PA)
High
26
Child Protection Referrals to
CYFS from HBDHB
Notifications to Child Youth and Family from HBDHB 2003 - 2008
120
100
80
60
40
20
0
Dec- Mar- Jun- Sep- Dec- Mar- Jun- Sep- Dec- Mar- Jun- Sep- Dec- Mar- Jun- Sep04
05
05
05
05
06
06
06
06
07
07
07
07
08
08
08
quarter
Fe
b
M a - 03
y
Au - 0 3
g
N o -0 3
v
F e -0 3
b
M a - 04
y
Au - 0 4
g
N o -0 4
v
F e -0 4
b
M a - 05
y
Au - 0 5
gN o 05
v
F e -0 5
b
M a - 06
y
Au - 0 6
g
N o -0 6
v
F e -0 6
b
M a - 07
y
Au - 0 7
g
N o -0 7
v
F e -0 7
b
M a - 08
y
Au - 0 8
g
N o -0 8
v -0
8
P e rc e n t a g e
Rates for Routine Questioning
for Partner Abuse within
Services
100
90
80
70
60
50
40
30
20
10
0
ED
AAU
Children's Ward
SCBU
CDU
PHN
Maternity, antenatal
Maternity, postnatal
Dental
Month of Audit
Partner abuse disclosures and
FV intervention
National overview
• VIP national program (Miranda Ritchie)
• AUT (Prof Jane Koziol-McLean)
contracted by MoH to audit all 21 DHBs’
FVI programs
• 4 annual cycles of audit
• Benchmarking and specific feedback
aimed at improving program
violence intervention
programme
Launched 1 August 2007
• FVI Coordinator positions in every DHB
• Continuation of:
–
–
–
–
National training
National evaluation
Resources production
Technical advise
• New resources:
– Website www.moh.govt.nz/familyviolence
– Violence & Young People Report
– FVIG: Elder abuse and neglect
Resources:
MoH VIP website
Monitoring
Monitoring&&
evaluation;
evaluation;National
National
Funded
FundedDHB
DHBFVIC
FVIC
evaluation,
evaluation,
VIP
VIPQIA
QIAResource
Resourcekit
kit
VIP
VIPTraining
Training
contracts
contracts
National
NationalVIP
VIP
Manager;
Manager;Technical
Technical
advice;
advice;NNFVIC
NNFVIC
meetings
meetings
FVIG;
FVIG;CA
CA&&PA
PA
Resources;
Resources;website,
website,
posters,
posters,cue
cuecards,
cards,
pamphlets
pamphlets
Monitoring,
Monitoring,audit
audit&&
evaluation
evaluation
Staff
Stafftraining
training
Senior
SeniorManagement
ManagementSupport
Support&&
Community
CommunityCollaboration
Collaboration
DHB
VIP
Policies,
Policies,
standardised
standardiseddocumentation
documentation
peer-support
peer-support
Resources;
Resources;, ,posters,
posters,
VIPC
VIPC
service
servicereorientation
reorientation
cue
cuecards,
cards,pamphlets
pamphlets
2008 overall score league table
Summary
• Child and partner abuse are common and have
devastating, long-term impacts on health
• FVI Guidelines -> opportunity to implement best
practice
• Comprehensive systems approach to
organisational and practice change
• Sustained increase in screening and referral
rates for child and partner abuse
• Improved quality of assessment also
demonstrated
• National program with resources on
www.moh.govt.nz
Questions?
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
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NZHIS morbidity and mortality data 1997-8.
NZ Police statistics.
Young W, Morris A, Cameron N, Haslett S. NZ National Survey of Crime Victims
1996. Wellington: Victimisation Survey Committee, 1997.
Morris A. Women’s Safety Survey, 1996. Wellington: Victimisation Survey
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Tjaden P, Thoennes N. Extent, nature and consequences of intimate partner
violence: Findings from the National Violence Against Women Survey. Department
of Justice and Centers for Disease Control and Prevention, July 2000.
Snively S. The New Zealand Economic Cost of Family Violence. Wellington:
Coopers and Lybrand 1994.
Leibrich J, Paulin J, Ransom R. Hitting Home: Men speak about abuse of women
partners. Wellington, Department of Justice, 1995.
Loring M, Smith R. Health care barriers and interventions for battered women.
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MacFarlane J, Parker B and Soeken K. Abuse during pregnancy: associations with
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Koss MP, Koss PG and Woodruff WJ. Deleterious effects of criminal victimisation
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Ross SM. Risk of physical abuse to children of spouse-abusing parents. Child
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Wolfe DA and Korsch B. Witnessing domestic violence during childhood and
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Maxwell GM. Children and violence: the unnoticed victims. Wellington: Office of
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Henning K, Leitenberg H, Coffey P, et al. Long term psychological adjustment to
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Sullivan CM and Bybee DI. Reducing violence through community advocacy for
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McFarlane J et al. Safety behaviours of abused women after an intervention during
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