Acceptability of routine domestic abuse enquiry within sexual health services

Introduction

An estimated 2.4 million adults in England and Wales experienced domestic abuse (DA) and over 1.3 million DA crimes were reported in England in the year ending March 2019. ¹ The COVID-19 pandemic has seen an increase in reported cases of DA, with one charity noting a 66% increase in emergency calls. ²

Routine DA enquiry in the antenatal setting is acceptable to women when conducted in a confidential environment by a trained healthcare professional, and repeated enquiry is of benefit. ³ Studies interviewing survivors have noted the reduced likelihood of disclosure in the absence of routine enquiry; whilst barriers to this identified by staff include time, training and fear of patient perceptions. ³ A high prevalence of DA has been identified in inner city sexual health services (SHS), with one study reporting that 46% of women attending had been affected. ⁴ A positive correlation between DA and diagnosis of a sexually transmitted infection has also been reported. ⁴ Alongside a confidential and protected environment, this suggests SHS are a priority setting for routine enquiry. Reassuringly, no adverse effects from screening interventions have been identified. ⁵

The British Association for Sexual Health and HIV (BASHH) toolkit recommends the Ask>Validate>Assess>Action framework to aid routine enquiry. ⁶ This was introduced into three West London SHS from April 2018 after targeted staff training. This survey aims to ascertain patient and staff attitudes towards the initiative.

Methods

Routine DA enquiry was undertaken at all clinic appointments, supported by an electronic record prompt using the BASHH toolkit. ⁶ Enquiry was targeted at the time since the last visit to avoid repetitive disclosures of historical DA. An optional training package was advertised and recommended to staff. Guidance to ensure safe provision of routine enquiry was in place.

Results

Patient survey

Of 562 invited patients, 226 responded to the invitation, a response rate of 40%. Of the 1.2 million people using SHS in England in 2019/20, ⁷ 82% were female and 18% male; therefore, our sample was representative. An overwhelming majority of patients were in favour of routine enquiry (Table 1).

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Table 1.

Patient survey results.

Patient survey responses
Variable	Patient responses N (%)
Age	<18	18–24	25–34	35–44	45–54	>54	No answer
	1 (0)	57 (25)	106 (47)	36 (16)	17 (8)	7 (3)	2 (1)
Gender	Female	Male	Trans-woman	Trans-man	Non-binary	Other	No answer
	161 (72)	61 (27)	0 (0)	0 (0)	0 (0)	1 (0)	3 (1)
Ethnicity	Black	White	Asian	Mixed	Other	No answer
	24 (11)	155 (69)	13 (6)	22 (10)	10 (4)	2 (1)
Sexual Orientation	Heterosexual	Bisexual	Gay	Lesbian	Other	No answer
	179 (80)	15 (7)	26 (12)	1 (0)	3 (1)	2 (1)
	Yes	No	Unsure	No answer
Were you asked about DA at your visit today?	220 (97)	6 (3)	0 (0)	0 (0)
Was it explained to you why we now ask about DA within your consultation?	199 (88)	15 (7)	6 (3)	6 (3)
Likert scale ratings	1 (Strongly disagree)	2	3	4	5 (Strongly agree)	No answer
How comfortable did you feel being asked about DA during your consultation?	1 (0)	1 (0)	10 (4)	19 (8)	187 (83)	8 (4)
How acceptable do you think it is to ask patients about DA in SHS?	1 (0)	1 (0)	10 (4)	24 (11)	190 (84)	0 (0)

Patient comments, ‘Many people who experience domestic abuse would maybe blame themselves or feel ashamed or unsafe sharing information elsewhere but may feel safe to share it with the people in sexual health clinics’. ‘Sexual health clinic is a good/safe place to try and identify these issues’. ‘I think it’s really important to embed talking about these issues into day-to-day conversations such as at the clinic here with a nurse. Very glad to see it’s become a part of that’. ‘Is domestic abuse really relevant as an issue while people are being tested and treated for STDs?’ ‘Definitely good to ask about – get people talking, break stigma’.

Staff survey

A representative sample of 51 staff members participated in the survey (36% response rate). Staff attitudes were overwhelmingly positive and comments gave insight into the pressures faced by those conducting routine enquiry (Table 2).

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Table 2.

Staff survey results.

Staff survey responses
Variable	Staff responses N (%)
Age	<18	18–24	25–34	35–44	45–54	>54
	0 (0)	0 (0)	19 (37)	15 (29)	12 (24)	5 (10)
Gender	Female	Male	Trans-woman	Trans-man	Non-Binary	No answer
	34 (67)	15 (29)	0 (0)	0 (0)	0 (0)	2 (4)
Ethnicity	Black	White	Asian	Mixed	Other	No answer
	3 (6)	37 (73)	1 (2)	6 (12)	4 (8)	0 (0)
Sexual Orientation	Heterosexual	Bisexual	Gay	Lesbian	Other	No answer
	28 (55)	3 (6)	15 (29)	0 (0)	3 (6)	2 (4)
Staff group	Nurse	Doctor	HCA	Health Adviser	Other	No answer
	22 (43)	16 (31)	4 (8)	6 (12)	3 (6)	0 (0)
Likert scale ratings	1 (Strongly disagree)	2	3	4	5 (Strongly agree)	No answer
How confident do you feel routinely asking about DA?	0 (0)	0 (0)	2 (4)	15 (29)	34 (67)	0 (0)
How acceptable do patients find being asked about DA?	0 (0)	0 (0)	4 (8)	27 (53)	20 (39)	0 (0)
How appropriate do you feel it is to routinely ask patients about DA?	0 (0)	2 (4)	2 (4)	11 (22)	36 (71)	0 (0)
	Yes	No	Sometimes	No answer
Have you received formal training about DA?	47 (92)	4 (8)	-	0 (0)
Do you explain to patients why we now ask about DA?	33 (66)	1 (2)	13 (25)	4 (8)
Are you a DA Link? (Staff members who have undertaken enhanced DA training)	18 (35)	29 (57)	-	4 (8)

Staff comments,‘Incredibly important question. Not many patients have answered yes but those who have, also said how grateful they were that the question had been asked, either to discuss it or to get support’. ‘Normalising enquiry is a first step to helping other areas in the main hospital to introduce it also. This initiative has enabled our teams to help many people who might otherwise have not accessed specialist support. All sexual health clinics should do this’. ‘I think the questions around domestic abuse are important and I do aim to ask as often as possible, but there are times when I find it challenging to ask the questions. This is often when the clinic is extremely busy or where I have had a clinic with several complex patients’. ‘If patients have answered this question before and there has been abuse in the past, they don’t like being asked again’.

Discussion

Patients received routine enquiry positively and felt it was appropriate to be asked. Multiple patients acknowledged the importance of normalising discussions about DA. The significance of staff members making patients feel comfortable was recognised and reflects the importance of training and supervision.

Staff responded positively but acknowledged the impact of disclosures on personal wellbeing, and having the confidence to deal with a disclosure. Three Independent Domestic Violence Advocates are available to refer to following a disclosure within the Trust.

There were limitations. Patients who felt strongly about DA may have been more likely to respond. The staff response rate may have been influenced by the emerging COVID-19 pandemic. However, the staff sample was representative and the number of those responding with enhanced DA training (36%) was only slightly higher than the proportion across the directorate (27%).

Furthermore, this study does not take into account the recent increase in remote consultations. Routine enquiry via phone or e-consultation needs to be carefully considered with regards to confidentiality and safety. ⁸

Overall, this survey demonstrates the success of routine enquiry within SHS, and the importance of formal staff support. It is hoped this will persuade other specialities to implement routine DA enquiry, in view of the simplicity of embedding this into clinical practice, with overwhelmingly positive feedback.