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? 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