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Family Violence

Questions and Answers

Why is family violence a health problem?

Family violence is common.

Prevalence of partner abuse internationally

In American studies, 20–30% of women reported being physically and/or sexually abused during their lifetime, compared with 7.5% of men (Dearwater et al 1998; Feldhaus et al 1997).

In Australian emergency department studies, the prevalence of partner abuse for women was 23% and, for men, 6–14.8% (de Vries Robbe et al 1996; Roberts et al 1993).

Prevalence of partner abuse in New Zealand

Lifetime incidence: Between 33 and 39% of women have been hit or forced to have sex by a partner at least once during their lifetime (Fanslow and Robinson 2004). Eighteen percent of men have been hit by a partner at least once during their lifetime (Morris and Reilly 2003).
Last year incidence: Five percent of women reported being physically or sexually abused by a partner or ex partner in the previous year (Fanslow and Robinson 2004). No preceding twelve months figures are available for men.
Leibrich et al conducted a random telephone survey of 2000 men (Leibrich et al 1996). This survey asked men to report if they had been a perpetrator of family violence, including physical, sexual and psychological abuse. Twenty-one percent of the men surveyed reported a low level incident of physical or sexual abuse against their partner on at least one occasion in the preceding 12 months, with the lifetime prevalence of physical or sexual abuse being 35%. Fifty- three percent of men reported psychological abusing their partner on at least one occasion in the preceding 12 months, with the lifetime prevalence of psychological abuse being 62%.
Emergency department studies on the prevalence of partner abuse for women showed 21% of women experiencing current abuse, with a lifetime prevalence of 44% (Koziol-McLain et al 2004).

Health effects of abuse

Significant, long-term, negative health effects result from victimisation, including emotional, medical and mental health effects.
Battered women use health services at greater rates than non-battered women (Fanslow and Robinson, 2004; Koss, Koss and Woodruff 1991).
A Swedish study compared admission rates for battered women and non-battered women over a 15-year period. The results suggest that admission rates were between 3 and 70 times higher for battered than for non-battered women (Bergman and Brismar 1991), as shown in Figure 1.

Figure 1
Graph entitled reasons for hospital admissions of battered women and matched control subjects period of 15 years 1973-1988 at Huddinge Hospital, Sweden.

Graph entitled reasons for hospital admissions of battered women and matched control subjects period of 15 years 1973-1988 at Huddinge Hospital, Sweden.

This graph details the results from a Swedish study by Bergman & Brismar from 1991. It highlights the impact of partner abuse on women's health across mental and physical health indicators. The study compared admission rates of women who were battered with a matched sample for a period of 15 years. The admission rates and the reason for the admission were compared. The rates of admissions for battered group were significantly higher across all groups. It is striking to note the odds ratios from 2 (surgery not trauma) to 70 (psychiatric).

Physical injuries include fractures, burns, head injuries, major trauma (Campbell et al 1994; Campbell 2002; Champian and Shain 1998; Fanslow et al 1998; Grisso et al 1999; Kyriacou et al 1999; Webster et al 1994).
Mental health effects include depression, anxiety and alcohol and drug abuse (Fanslow and Robinson 2004; Morris 1996; Mullen et al 1988).
Health effects during pregnancy include increased risk of miscarriage, premature delivery and low-birth-weight babies (Parker et al 1994; Parker et al 1999).

Child abuse
Studies have shown child abuse and partner abuse co-occur in 30–60% of families (Campbell 1994; Edelson 1999).

The likelihood of co-occurrence increases with increasing frequency of partner abuse.

If child abuse is identified, then an assessment for partner abuse should occur. If partner abuse is disclosed, then an assessment for child abuse should occur.

Prevalence of child abuse in New Zealand

About 4–8% of New Zealand children experience physical abuse. Of this group:

8% regularly experience physical punishment
4% have experienced severe or harsh and abusive treatment
punches around the head and body (65%)
beatings with a cane, strap or other object (57%)
kicks (52%)
80% suffer injury as a result of physical abuse
37% are also sexually abused (Ferguson et al 1997).
Twenty two percent of girls and 11% of boys experience sexual abuse, excluding non-contact sexual abuse (e.g. being forced to watch pornographic material) (Ferguson et al 1997).

Childhood abuse is associated with increased risk of victimisation later in life (Ferguson, 1997).

In 2005, Child, Youth and Family Service (CYFS) report they received 53,097 notifications of child abuse, of which 43,460 required further action by Social Worker (CYFS, 2005).

Violence affects a victim’s health. Because health professionals come into contact with the majority of the population, they are well placed to identify abuse, assess risk and refer victims to appropriate services.

Why does the health service need to offer family violence intervention?

Violence and abuse cause significant and cumulative health harm - the longer violence and abuse continues, the worse the mental and physical health harm. Victims of violence use services at approximately three times the rate of people who are not victimised (Fanslow 2004, Krug 2002; Koss, Koss & Woodruff 1991). The Adverse Childhood Experiences (ACE) study suggests that being a victim of child abuse and/or witnessing partner abuse is linked to serious health problems in adulthood (Felitti et al 1998).

Early intervention provided by health professionals' identification and support of child and adult victims is important to reduce health harm, social harm and health service utilisation. The Family Violence Intervention Guidelines intervention is highly acceptable to patients, increases help-seeking behaviour, and reduces medium term incidence of violence (Koziol-Mc Lain et al 2005, McFarlane et al, 1998 and 2000, Muellman et al 1999).

International recognition of the significance of family violence

The seriousness of family violence is recognised by international organisations, conventions and documents, including:

World Health Organization violence publications
United Nations Convention on the Rights of a Child
United Nations Declaration of the Elimination of Violence against Women

National recognition of the significance of family violence for the health sector

The New Zealand Government recognises family violence as a priority issue, as shown in:

the Ministry of Health’s Statement of Intent 1 July 2005 to 30 June 2006 (Ministry of Health 2005)
The New Zealand Health Strategy (Minister of Health 2000)
the Child Health Strategy (Minister of Health 1998)
The Primary Health Care Strategy (Minister of Health 2001)
He Korowai Oranga: Māori Health Strategy (Minister of Health and Associate Minister of Health 2002)
The Crown Funding Agreement with DHBs

Health professionals

Health professionals have more access to families than almost any other service provider. Health professionals have the opportunity to identify abuse early, provide immediate support and offer referrals, which could prevent serious harm or death.

Health professionals have a professional responsibility to act as an advocate for victims of abuse (Nursing Council of New Zealand 2001).

Health professionals have an ethical responsibility to diagnose appropriately.

The ethical principle of beneficence suggests that health professionals have a professional responsibility to diagnose and treat abuse rather than to merely address physical symptoms.

The health professional should address the cause because failure to do so is likely to lead to further injury. For example, if abuse is the underlying reason for a health issue and it is not identified, then any treatment may be ineffective and even detrimental (McLeer and Anwar 1997; Spinola et al 1998)

Health professionals who adopt an abuse screening practice within their usual health assessment increase opportunities to provide early intervention and education on family violence.

Victims

Victims feel that health professionals should be able to provide support and offer intervention options (Campbell et al 1994, Koziol- McLain 2005).

New Zealand victims of violence who have experienced the health service intervention are strongly positive about the impact of in providing support and information, and assisting in help seeking (Koziol-McLain et al 2005, DSAC 2005). Early intervention reduces longer term health service utilisation.

Victims have identified that when a health professional does not ask about their safety or screen for violence, they can feel helpless, discouraged, (Campbell et al 1994) and less likely to seek help in the future (Head and Taft 1995).

Victims will usually disclose violence if asked in a safe, non-judgmental way within the context of a health assessment (Freidman et al 1992, Koziol-McLain et al 2005).

How do you engage key stakeholders in the family violence intervention programme?

Senior management/funding team

Make presentations to District Health Boards (DHBs) and or senior management teams to raise their awareness and understanding of the prevalence and health impact of family violence on DHB services.
For further information contact the National VIP Manager for DHBs National.Manager@hawkesbaydhb.govt.nz for further information.
The Ministry of Health Funding Agreement requires DHB planning and funding teams to report on their implementation of family violence intervention guidelines. In 2005/6 the Ministry of Health requires DHB s to report on how they will improve their scores on the annual Ministry of Health Audit of DHB Responsiveness to Family Violence.
Use results of the Ministry of Health Audit of DHB Responsiveness to Family Violence to assess needs for development within DHBs. Audit findings including national trends are available.
AUT Evaluation Audit website (www.aut.ac.nz).

Health professionals
Emergency departments

Prevalence studies have identified that approximately one in four women presenting at emergency departments may be victims of abuse (de Vries Robbe et al 1996; Koziol McLain et al 2004; Roberts et al 1993).

Assessing for abuse is as important as completing risk assessments for patients presenting with any other condition. Emergency departments routinely screen for tetanus, but family violence is more common than tetanus as a health issue.

Paediatrics
The co-occurrence of child and partner abuse means that identifying partner abuse will increase the chances of identifying children at risk (Campbell 1994; McKibben et al 1989)

Maternity

As many as one in six pregnant women may be victims of abuse and partner abuse may sometimes begin during the pregnancy (McFarlane et al 1992; McFarlane et al 1996a, 1996b).
Prevalence rates during pregnancy are higher in the later stages of pregnancy.
Women in abusive relationships often delay the onset of seeking antenatal care.

(McFarlane et al 1992; McFarlane et al 1996a, 1996b; Norton et al 1995; Webster et al 1994)

Community agencies
The community agencies are the family violence intervention experts (see 2e.Collaborating with Community Agencies). As such, health professionals should recognise the importance of working with community agencies in a partnership approach when offering family violence interventions.

Engaging community agencies early in the family violence intervention programme’s development is useful to develop a collaborative working relationship between the DHB and the major referral agencies. The experience of these community agencies can also be helpful in establishing the DHB response.

Offer agencies opportunities to be part of both the family violence intervention programme steering group and training in order to:

increase their understanding of the DHB family violence intervention programme
indicate their support of the programme.

Community agencies may make presentations to the steering group to raise awareness of family violence and the recommended interventions.

Why should child and partner abuse intervention be linked?
Studies show a high co-occurrence of child and partner abuse - 30% (Campbell 1994) and 59% (McKibben et al 1989).

The Family Violence Intervention Guidelines: Child and Partner Abuse (Ministry of Health 2002) recommends that:

if partner abuse is identified that a risk assessment be undertaken for child abuse
if child abuse is identified, that a risk assessment be undertaken for partner abuse.

This dual risk assessment increases the opportunities to identify abuse, and allows intervention to be offered for all victimised family members. As witnessing partner violence has similar mental health outcomes for children as being the direct victim of child abuse, it is important to assess the safety and well being of children. Identifying partner abuse can be the first step in assisting access to support for both mothers and children through local referral agencies.

Living in a household where a child' s mother is abused is similar in traumatic affect to children as direct child abuse. The Adverse Childhood Experiences (ACE) study suggests that being a victim of child abuse and/or witnessing partner abuse is linked to serious health problems in adulthood (Felitti et al 1998).

Should you screen for child abuse?
There is currently no sensitive, specific, validated screening instrument for child abuse.

The Family Violence Intervention Guidelines: Child and Partner Abuse (Ministry of Health 2002) recommends that a comprehensive risk assessment of child abuse and neglect be completed for high-risk groups and/or if signs and symptoms suggest abuse.

See Appendix A (High risk indicators associated with child abuse), B (Sign and symptoms associated with child abuse and neglect, & C (HEADSS assessment) of the Family Violence Intervention Guidelines: Child and partner abuse

Why are men not screened for partner abuse?
The Family Violence Intervention Guidelines: Child and Partner Abuse (Ministry of Health 2002) recommends that men be assessed if there is a suspicion that they have been abused.

Partner violence for men does not meet the criteria for a health-screening programme due to lack of evidence of health impact. A New Zealand study demonstrates that males who have been hit by females partners report needing no first aid, medical or hospital treatment compared with 17% of women who were hit by their male partners (Langley et al 1997).

Kimmel (2002) acknowledges that prevalence rates of males reporting violence from partners may compare those reported by females. He also notes that perpetrators of systematic, persistent and serious violence are predominantly men.

How do you maintain the privacy of the patient information you receive?
Individual DHBs need to develop a process to manage patient information, recognising the following principles.

A standardised form must be used to encourage methodical documentation of the abuse disclosure.
See Appendices D,E,F & I of the Family Violence Intervention Guidelines: Child and partner abuse.
The information must be stored securely to ensure that the patient’s partner cannot access it.
The information should be recorded so that it can be communicated between services. View the Privacy Discussion Paper (in Part Two of the Establishing a VIP Programme guide)

Is it mandatory to report abuse?
In New Zealand, it is not mandatory to report partner and child abuse.

Child abuse
Best practice recommends staff who identify or suspect child abuse report their concerns to a statutory agency, the police or a Child, Youth and Family service. In some DHBs this is mandatory.

Health professionals should recognise the paramountcy principle for child care: ‘[the] welfare and best interests of the child or young person shall be the first and paramount consideration.’ (section 6 of the Children, Young Persons and Their Families Act 1989).

Health providers have a statutory obligation to disclose information to a Child, Youth and Family service or the police when the information is required to determine whether the child needs care and protection (section 66 of the Children, Young Persons and Their Families Act 1989).

Partner abuse
In most circumstances concerning an adult victim of partner abuse, the victim should be empowered to take a variety of actions themselves. This can be achieved by providing the victim with an active referral to contact community/hospital-based services at any time (for example offering support and privacy to enable a victim to call an agency at the initial DHB assessment).

See Appendix K, Excerpts from relevant legislation in the Family Violence Intervention Guidelines: Child and partner abuse

If a clear, serious and imminent danger of partner abuse exists, staff may report the threat to the police without the potential victim’s consent (sections 151–210 of the Crimes Act 1961).

How do you manage training? Is it specific to the providers’ roles, or do nurses, doctors and other clinicians attend the same training?
Awareness and introductory training can be generic.

Basic training should cover the core knowledge and skills needed for family violence intervention, focusing on the six-step intervention model:

Identify.
Acknowledge the disclosure.
Assess risk.
Discuss safety.
Document.
Refer to a community agency.

(Fanslow, 2002) Family Violence Intervention Guidelines: Child and partner abuse

While training can be generic, grouping attendees by seniority, specialty and designation may help target the training to an appropriate level of clinical practice.

Role-playing will be more effective if scenarios have a specific department focus and the attendees are grouped into areas of similar practice.

What intervention is offered for elder abuse?
Family Violence Intervention Guidelines: Elder abuse and neglect is available to download or you can order hard copies.

If elder abuse is suspected, the person should be assessed and referred to the appropriate services. For additional information contact your local Age Concern group:
www.ageconcern.org.nz

What outcomes can you expect from introducing a family violence intervention programme? How do you know you are making a difference?
Customer satisfaction rates will increase, and victims will give positive feedback about the health professional offering family violence intervention.

Rates of routine questioning and victim identification will rise across services.

Rates of referrals from health services to community agencies will increase.

The DHB’s score on the Ministry of Health Audit of DHB responsiveness to family violence will improve.

Longer-term outcomes may include:

decreased utilisation of health services
reduced long-term rates of family violence
children growing up in safer families
breaking the cycle of violence.

How can the quality of family violence intervention be measured and maintained?
To ensure the quality and safety of the intervention supervision/peer support should be provided for heath professionals when they first begin family violence intervention (after a disclosure of abuse). This allows staff to:

assess their standard of practice during self-reflective learning
receive the necessary emotional and professional support regarding practice.

Pre- and post-teaching evaluations can assess how much staff understand about family violence intervention before and after the training session. This helps the training co-ordinator assess where additional support is necessary to ensure quality intervention is offered. See Training Evaluation

Audits should be conducted regularly to assess:

the staff’s knowledge and understanding of family violence intervention policies
abuse screening rates and standards of documentation.

Staff should be interviewed regularly to assess the barriers that need to be addressed and possible avenues for family violence interventions within their practice.

Quarterly feedback from the community agencies who receive referrals from the DHB is an effective way of monitoring that the quality and quantity of referrals has increased since a family violence intervention programme’s inception.

Page last updated: 1 August 2007