2.1.3 Elizabeth McLindon
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2.1.3 AWHN Conference 6 2010 Federation: The Women’s Says No to Violence Against Women The Royal Women’s Hospital Violence Prevention Strategy
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2.1.3 Elizabeth McLindon
- 1. The Women’s Says No to Violence Against Women The Royal Women’s Hospital Violence Prevention Strategy Presenter: Elizabeth McLindon Authors: Elizabeth McLindon & Helen Makregiorgos Women’s Social Support Services (Social Work)
- 2. About us • We are Australia’s largest tertiary hospital specialising in the health of women & babies • We practice using a social model of health recognising the social & cultural determinants of women’s lives • We provide about 200,000 episodes of care each year • Our community of women speak 60 different languages & follow 42 separate faiths
- 3. Overview of the strategy The Women’s No to Violence Strategy: • Primary prevention: preventing violence before it has occurred • Secondary prevention: growing the capacity of health professionals to respond to the issue • Tertiary prevention: improving women’s access to specialist services Our Strategy is consistent with the National Council's Plan for Australia to Reduce Violence Against Women and their Children 2009-2021 (Commonwealth of Australia 2009)
- 4. Definition of VAW Broad definition of violence against women (VAW) as diverse & complex: An act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or private life. (WHO 2005)
- 5. Nature of VAW Including: •Childhood abuse •Witnessing of family violence •Sexual harassment in the workplace •Intimate partner, family & domestic violence •Elder abuse •Female cutting / female genital mutilation •Trafficking and forced prostitution •Sexual assault •Drug & alcohol facilitated sexual assault •Pornography •Discrimination WHO 2008
- 6. Prevalence of VAW • 1 in 3 Australian women experience physical violence in their lifetime (ABS 2005) • 1 in 5 experience sexual violence (ABS 2005) • Higher prevalence for Indigenous women, women with disabilities, culturally & linguistically diverse women & sex workers (ABS 2005)
- 7. Impacts of VAW • Physical, emotional and psychological • Reproductive and sexual health • Intimate relationships • Family and friends – infants, children & young people • Housing and safety • Education, finance, employment • Spiritual and world view • Intergenerational • Health care access and treatment WHO 2005 & VicHealth 2004
- 8. The role of health services • Women who experience violence are more likely to present to health services due to immediate, short and long term consequences (Warshaw & Alpert 1999) • During pregnancy & in the post natal period women are at increased risk of violence (WHO 2005) • Health services can have a positive impact for women when their responses are informed by evidence, i.e. advocacy based interventions, information and referral to specialist services (Wathen & MacMillan 2003) • Health services can play a critical role in leading primary prevention activities in the community (WHO 2002)
- 9. Current health sector gaps Gaps in primary, secondary & tertiary prevention interventions, for example: • Policies and procedures (ie. Clinical Practice Guideline) • Training and education • Community education • Direct services
- 10. VAW strategy: Primary prevention CASA HOUSE Sexual Assault Prevention Program for Secondary Schools (SAPPSS): • Changing the attitudes and behaviours of young men & women through a whole-of-school, principal lead commitment to violence prevention • Professional development for teachers and school staff, policy & procedures to support the program, Year 9/10 student curriculum, partnerships with local sexual assault & domestic violence services • Focus on long-term sustainable cultural change meets standards for best practice & has produced encouraging results (VicHealth 2009)
- 11. VAW strategy: Secondary prevention • The Women’s Clinical Practice Guideline (CPG) for the management of violence against women • Health professionals training • Leadership Program • Community education program - Information, posters & staff badges directed at consumers
- 15. VAW strategy: Tertiary prevention • Women’s Social Support Service • CASA House (Centre Against Sexual Assault) • Sexual Assault Crisis Line • Aboriginal Women Health Business Unit • Family and Reproductive Rights Education Program
- 16. How we developed the Strategy Developed using evidence of best practice: • Literature review • Current practice, e.g. auditing, focus groups • Practice-based evidence from consultation with staff & external agencies Organisational support: • Leadership • Expertise • Resources
- 17. Recommendations Acute health services should develop a whole-of organisation response to the issue of violence against women. Including: • An organisational mandate to address violence against women, with engagement by senior staff & reflection in strategic planning • The development of a clinical practice guideline & training for staff • The advancement of a multi-intervention strategy aimed at the prevention of violence against women, the improvement of early intervention efforts & the extension of actions taken once violence has occurred
- 18. Recommendations (cont.) The Women’s supports improvement to the current fragmented system of policy & service delivery for women who have experienced violence. Specifically recommending: • A mandated role for hospitals & primary health care services in addressing violence against women • Government supported training & support services for health professionals • A planning framework for greater consistency, communication & collaboration within the health care sector as well as integration with the sexual assault & family violence, judicial, housing & mental health services.
- 19. Contact us Women’s Social Support Services E: social.support@thewomens.org.au W:www.thewomens.org.au T: (03) 8345 3050
Editor's Notes
- The RWH recognises violence against women is prevalent, serious and preventable Unique health service strategy – There are few international examples of a comprehensive health care response to violence against women: - In Canada, BC Women’s Hospital and Health Centre in Vancouver have developed a prevention program which includes clinical support and training for health care professionals, secondary consultation and professional resources (BC Women’s Hospital and Health Centre 2010 [24]). - In the Philippines, the Philippines General Hospital has comprehensive tertiary prevention strategies including a Crisis Centre and psychosocial follow-up for women who have disclosed violence, as well as secondary prevention actions of training for health care providers and research (Philippine General Hospital 2010 [25]). Primary prevention: is used to identify actions that aim to prevent violence before it has occurred (VicHealth 2007 [8]). Secondary prevention: is referred to as early intervention - actions taken when there are early warning signs of violence or significant risk factors for its occurrence (VicHealth 2007 [8]). Tertiary prevention: represents interventions that occur after an episode of violence and can include actions to prevent further violence from occurring (VicHealth 2007 [8]). The Women’s Strategy has been developed over a long period of time, although become a whole of organisation approach in 2006. Released in 2009, The National Council’s plan titled Time for Action: The National Council’s Plan for Australia to Reduce Violence Against Women and their Children 2009-2021 (Commonwealth of Australia 2009 [5]), prioritises an integrated, preventative approach between health and other social services as well as across health services (Commonwealth of Australia 2009 [5]). Based in the latest evidence, this plan identifies the importance of a whole-of-community-approach that includes engaging the health sector; “The first door must be the right door” means that for women who have experienced violence, their first point of contact should provide professional and compassionate assistance, and that the complexity and entirety of their needs are met…the first point of contact may be…a health…service (Commonwealth of Australia 2009 p, 77-8 [5]). Slide references BC Women’s Hospital and Health Centre in Vancouver, Canada (2010). [Accessed 30.03.10]. Available from World Wide Web: http://www.bcwomens.ca/Services/HealthServices/WomanAbuseResponse/Services.htm). Philippines General Hospital (2010). [Accessed 30.03.10]. Available from World Wide Web: http://www.unifem-eseasia.org/projects/evaw/vawngo/vamphil.htm#six VicHealth (2004). The health costs of violence. Measuring the burden of disease caused by intimate partner violence. Victoria: Victorian Health Promotion Foundation. Commonwealth of Australia (2009) Time for Action: The National Council’s Plan for Australia to Reduce Violence Against Women and their Children 2009-2021. Canberra: Commonwealth of Australia).
- Violence against women is a significant social and economic issue in Australia and a common experience in the lives of Australian women (Australian Bureau of Statistics [ABS] 2005 [2]). It has detrimental psychological and physical, cultural and spiritual, consequences for women and their communities (VicHealth 2004 [3]). Slide references: WHO (2005). WHO multi-country study on women’s health and domestic violence against women: summary report of initial results on prevalence, health outcomes and women’s responses. Geneva: World Health Organization.
- The Women’s acknowledges that violence is most often an abuse of power against women perpetrated in the great majority of instances by men (World Health Organisation [WHO] 2008 [6]; ABS 2004 [7]). Victorian Family Violence Protection Act 2008 includes a broad definition of family violence and acknowledges children witnessing violence as a crime: a)Behaviour by a person towards a family member if that behaviour – (i)Is physically or sexually abusive; or (ii)Is emotionally or psychologically abusive; or (iii)Is economically abusive; or (iv)Is threatening; or (v)Is coercive; or (vi)In any other way controls or dominates the family member and causes that family member to feel fear for the safety or well being of that family member or another person; or b) Behaviour by a person that causes a child to hear or witness, or otherwise be exposed to the effects of, behaviours referred to in paragraph (a). Slide References 1.World Health Organisation (2008). ‘Health-sector responses to intimate partner violence in low- and middle-income settings: a review of current models, challenges and opportunities’, Bulletin of the World Health Organisation, 86 (8), 577-656. [Online], [Accessed 17.04.10]. Available from World Wide Web: http://www.who.int/bulletin/volumes/86/8/07-045906-ab/en/ 2. Australian Bureau of Statistics (2004). Sexual Assault in Australia: A Statistical Overview, No. 4523.0. Canberra: Australian Bureau of Statistics.
- Slide 6: Prevalence of VAW Using Burden of Disease methodology, VicHealth (2004) found that intimate partner violence is the leading contributor to death, disability & illness in Victorian women aged 15 to 44 years (VicHealth 2004). It contributes nine per cent to the total disease burden for women during that time in their lives and three per cent in all women (VicHealth 2004 [3]). Costs Australia $13.6 billion each year (KPMG 2009) and this is expected to rise to $15.6 billion by 2021 (KPMG 2009 [11]) Stats. vary because of definitions of violence and nature of crime often means women are reluctant to disclose, so accepted rates are often under estimates. International research into prevalence of violence against women documents even higher incidence rates (Mouzos & Makkai 2004 [9]; WHO 2002 [10]). Reference list: 1. VicHealth (2004). The health costs of violence. Measuring the burden of disease caused by intimate partner violence. Victoria: Victorian Health Promotion Foundation. 2. KPMG (2009). The Cost of Violence against Women and their Children. Safety Taskforce, Department of Families, Housing, Community Services and Indigenous Affairs, Australian Government. 3. Mouzos, J. and Makkai, T. (2004). Women’s Experiences of Male Violence: Findings From the Australian Component of the International Violence Against Women Survey. Canberra: Australian Institute of Criminology. 4. World Health Organisation (2002). World Report on Violence and Health. Geneva: World Health Organisation.
- Pregnancy: Clinical studies in emergency departments and antenatal clinics indicate between 19% and 25.7% of women are subjected to domestic and family violence over their lifetimes (Hegarty, Hindmarch & Gilles, 2000). Some 42% of all women responding to the Women’s Safety Survey who reported that they had exp. Violence @ some time in their lives reported they were pregnant at the time of the violence (WHO 2000). Other women’s health impacts: - Infrequent or late presentations for antenatal care - Reluctance to undertake certain procedures such as internal vaginal examinations or pap tests -Declining assistance with breast feeding - Feeling uncomfortable or distressed with a male doctor - Wo. reporting intimate partner violence are more likely to have an abnormal pap smear, vaginal or endo-cervical infection (Quinlivan & Evans 2001). - Young wo. are more likely to have an unplanned preg., a TOP or miscarriage (Taft 2002) & their babies are more likely to have a prob. Diagnosed after birth (Quinlivan & Evans 2001). - Impacts on emotional & psychological health will mean an overrepresentation in the mental health service system (Spataro, Mullen, Burgess, Wells & Moss [16] 2004) Slide references: Hegarty, K., Hindmarch, E. & Gilles, M. (2000). ‘Domestic Violence in Australia: definition, prevalence and nature of presentation in clinical practice’, The Medical Journal of Australia, 173, 363-367. WHO 2000 ???? Quinlivan, J. and Evans, S. (2001). ‘A prospective cohort study of the impact of domestic violence on young teenage pregnancy outcomes’, Journal of Paediatric and Adolescent Gynaecology, 14, 17-23. Spataro, J., Mullen, P., Burgess, P., Wells, D. and Moss, S. (2004). ‘Impact of child sexual abuse on mental health. Prospective study in males and females’, British Journal of Psychiatry, 184, 416-421. 5. VicHealth (2004). The health costs of violence. Measuring the burden of disease caused by intimate partner violence. Victoria: Victorian Health Promotion Foundation. World Health Organisation (2005). WHO Multi-country Study on Women's Health and Domestic Violence against Women. [Accessed 17.04.10]. Available from World Wide Web: http://www.who.int/gender/violence/who_multicountry_study/summary_report/summary_report_English2.pdf
- The first point of contact for women experiencing violence may be health services - placing health professionals in a unique position to assist women (WHO, 2002). Research shows that women will access health services across their lifespan and these services play a critical role in responding to the health impacts of violence (Taft 2002 [1]). Services and service providers that understand and are responsive to women can contribute to reducing the detrimental health consequences for them; that can endure for decades. By contrast, the literature reviewed states that, services that are unable to recognise and respond to women’s needs are part of a huge problem that can be exacerbated over time. (Poole, 2006; Taft, 2003; WHO, 2000, Makregiorgos, 2009) Some research suggests that disclosures of violence are often made in primary health and mental health settings, making them critical sites for intervention and prevention (Warshaw & Alpert 1999 [19]), while other research indicates that unless asked, women will rarely volunteer the information (Hegarty & Taft 2001 [20]). However, once a woman who has experienced violence has been identified by a health service, her contact with that service provides an important and perhaps exclusive opportunity for information, referral, advocacy and support (Taft 2002 [1]). Screening: Studies show that women do not mind being asked about their experience of violence (Davidson, King, Garcia & Marchant 2000 [21]), however the way this is responded to by the health professional is crucial to not only identifying violence, but also the woman’s recovery, and there is criticism of the current popular method of ‘screening’ as is occurring in the Australian states of Queensland and New South Wales as well as the United Kingdom, because unless staff are properly trained to respond to the issue, they can have a harmful impact (Taft 2002 [1]). What women tell us about their experiences in health care settings: - I felt trapped and powerless, could not get away. Very angry and resentful. I felt very humiliated. I felt she was rough, and it took too long. I could not wait to get out of there. - One woman doctor warmed the instruments and she explained everything she was doing as did it like ‘just now I will do this and now I will do this’ so I know what she will do to me so it was less uncomfortable. (CASA House, 2002) Slide references 1. Warshaw, C. and Alpert, E. (1999). ‘Integrating Routine Inquiry about Domestic Violence into Daily Practice’, Annals of Internal Medicine, 131 (8), 619-620. 2.World Health Organisation (2005). 2. WHO Multi-country Study on Women's Health and Domestic Violence against Women. [Accessed 17.04.10]. Available from World Wide Web: http://www.who.int/gender/violence/who_multicountry_study/summary_report/summary_report_English2.pdf 3.Wathen, C. and MacMillan, H. (2003). ‘Interventions for violence against women: scientific review’, Journal of the American Medical Association (JAMA), 289, 589-600.4. World Health Organisation (2002). World Report on Violence and Health. Geneva: World Health Organisation.
- Speak to these notes before referring to the slide: The health system continues to not address VAW in a structural and coordinated manner in Australia (Chan, 2009 – unpublished, RWH project report) Health services continue to focus on crisis care responses, i.e. Crisis response to recent victim/survivors of sexual assault (counsellor/advocate and where in line with protocols forensic medical officers and police (VicHealth, 2007).
- Primary prevention: - Sexual Assault Prevention Program for Secondary Schools (SAPPSS) developed initially in 2004 as 6-month pilot program - Evidenced-based program that aims to create a principal-led, whole-of-community approach to preventing sexual assault by educating young men and women about respectful relationships, consent, communication and sexual violence - Key components are staff professional development, Train the Trainer workshops, policy and procedures to support the program, Year 9/10 student curriculum support, a senior school Peer Educator program and partnerships with local sexual assault and domestic violence services - Over 200 teachers and school staff have participated in the Train the Trainer component of SAPPSS, which has enabled the delivery of sexual assault prevention and respectful relationships education to 1000’s of young people - An international review of the evidence into violence prevention and respectful relationships education by VicHealth (2009 [27]) found that SAPPSS’ focus on long-term sustainable cultural change through its commitment to a whole-school approach meets standards for best practice and has produced encouraging result With support from both Federal and State governments, SAPPSS is currently being implemented in twenty schools across Melbourne as well as in schools in Canberra and Darwin. Slide references: VicHealth (2009). Respectful Relationships Education. Violence prevention and respectful relationships education in Victorian secondary schools. Victoria: Department of Education and Early Childhood Development. [Accessed 23.04.10]. Available from World Wide Web: http://www.vichealth.vic.gov.au/~/media/ProgramsandProjects/MentalHealthandWellBeing/DiscriminationandViolence/ViolenceAgainstWomen/respectful-relationships.ashx
- Current evidence health care providers and settings should: - Develop and implement protocols for referral of women who have experienced IPV - Be alert to signs and symptoms and ask questions about violence when indicators are present - Ensure women are asked in a sensitive and appropriate manner that leads to discussion to determine women’s needs, safety concerns, etc CPG: In response to this, The Women’s has developed in 2006 to standardise the hospital response to this endemic problem. The guiding principle of the CPG is; “A central element of the experience of violence is a loss of control and feeling of powerlessness, therefore the governing principle is to give all women as much sense of control over their health care as possible” (The Women’s 2006, p. 1 [28]). - This is achieved through:Information Communication Identifying indicators of risk Linking health impacts with violence Respect Consultation and referral - The CPG documents the health impacts of violence, recognises effects on staff and provides a step-by-step guide to its management within a safe and supportive environment. Once it was developed, 60 senior management staff from across the hospital attended a one-day training session, preparing them for the introduction of the strategy and their leadership role within the organisation. Health Professionals Training: - WSSS, The Women’s Social Work service - and CASA House co-facilitate a 1-day workshop for midwifery, nursing, medical and allied health professionals within the hospital. - Training is built on the evidence-base about the nature and consequences of violence, its multifaceted health impacts and the key issues relevant to competency in identifying and inquiring about experiences, as well as skill in linking women with specialist services - Training first run in 2006 and 60 senior management attended. Since then over 200 staff have attended - Pre-and-post evaluations indicate a change in understanding about violence and confidence with taking action as a result of participation. In 2010 The Women’s will extend the training to health professionals from other health services in Victoria. - - WSSS and CASA House also run tailored Violence Against Women training and education sessions throughout the year within the hospital and for external service providers. Leadership group: - Held bi-monthly, this is an ongoing opportunity for professional development, debriefing and support. The VAW Leaders are staff that: - Have attended a one day workshop - Self nominate to take up the role; - Attend regular leadership groups that provide ongoing professional development Community education program: Information, posters and staff badges: - Community Education Program Community is defined as staff and women accessing the hospital. Purpose is to communicate explicitly with staff, women and visitors that this organisation believes VAW is a human rights issues and increase awareness of women’s rights and service options Within waiting areas of the hospital, there are posters that address the issue of gender-based violence its impact on health and women’s access to support Data was captured for the first year after the posters were erected and self-referrals to WSSS and CASA House increased. - Health professionals who have completed the 1-day training are invited to wear a badge identifying them as somebody that women can talk to about their experiences To address the distinct experience of pregnancy and childbirth for women who have experienced child sexual assault, written information in the form of two separate booklets has been developed, focusing on the potential experiences and care issues for both women and for their health care providers (The Women’s 2008 [29 & 30]).
- One example was a woman who had experienced childhood sexual assault and was seeing a gynaecologist. The woman experienced flashback during the appointment and saw the poster in the waiting area. The woman contacted CASA House and accessed counselling and support – this was her first disclosure.
- WSSS: - WSSS screen all women - In response to disclosure of violence, complete risk assessment incl. unborn and/or child/ren risk assessment; safety planning; community linkage; social work counselling; safety planning; risk assessment; support; information & advocacy - Our demand continues to rise – in 2009, WSSS engaged and provided interventions with 6,000 women - A snapshot of caseload data was taken for one month early in 2010, and of the 380 women engaged with the service, thirty-three per cent reported historical or current experiences of gender-based violence. - For many of these women, WSSS will be the only social support service they access and the first service to whom they will disclose experiences of violence against them CASA House: - 24-hour crisis care to recent victim/survivors of sexual assault; telephone support; short-term counselling; support groups & advocacy; community education; secondary consultation. - In 2009, 802 women accessed CASA House for individual counselling, 167 for duty appointments, 116 women engaged in group work and 138 women accessed a crisis care unit. The Sexual Assault Crisis Line (SACL): - 24-hour state-wide telephone counselling service for victim/survivors of sexual assault In 2009, SACL received 12,000 phone calls and coordinated 700 crisis care units for women requiring immediate medical, legal and crisis intervention relating to a recent sexual assault. - The Women’s Aboriginal Women’s Health Business Unit (AWHBU): Culturally specific support, information & advocacy to Aboriginal and Torres Strait Islander women - Service provides culturally specific support, information and advocacy to Aboriginal and Torres Strait Islander women attending The Women’s. - In 2009, AWHBU worked with 600 women, 80-90% of whom disclosed current or past experiences of gender-based violence, predominantly intimate partner violence, sexual assault and child sexual assault. FARREP (Family and reproductive rights education program): - for women from communities affected by FGM, they see 1000 women p/year
- Organisational support: CEO support & where possible introduces all one day training sessions Part of the Women’s strategic plan Support for specialist services to undertake the work - WSSS, CASA House & SACL Slide references: Practice based evidence - Epstein, I. (2001). ‘Available Clinical Information in Practice Based Research: Mining for Silver While Dreaming of Gold’, in I. Epstein & S. Blumenfield (Eds), Clinical Data-Mining in Practice Based Research. The Haworth Press, Inc.
- Two core recommendations emerge from The Women’s Strategy results: - To properly address the issue of violence against women, international research as well as the National Plan 2009-2021 (Commonwealth of Australia 2009 [5]) argue that the health sector must be engaged at a primary, secondary and tertiary level of intervention.
- - With the development of a National Council Plan to Reduce Violence against Women and their Children, the Federal government has a unique opportunity to coordinate the development of a strategy for building capacity across the health system. - Opportunity with the following National and State approaches being announced to ensure the health system is integral rather than peripheral to the prevention of VAW and the response to women currently experiencing VAW -VAW needs to be identified as a key issue that the health sector needs to incorporate into their models of care, i.e. Victorian government requiring hospitals to provide diversity plans Slide references: National Council to Reduce Violence against Women and their Children (the council) Time for Action: National Council’s Plan to Reduce Violence against Women and their Children, 2009-2021.