Primary care plays a key role in responding to patients experiencing or perpetrating domestic violence and abuse regardless of their gender, age, sexuality, or experience. There is, however, uncertainty about the value and effectiveness of integrated training and support programmes addressing the needs of all patients affected by domestic abuse.
IRIS (Identification and Referral to Improve Safety) is a broadly commissioned, evidence-based primary care training and support programme designed to reach female survivors of domestic violence and abuse through general practice. The IRIS+ (Enhanced Identification and Referral to Improve Safety) study tested the feasibility of an adaptation of IRIS for all patients affected by domestic abuse, including men and children.
Reaching everyone in general practice?
Challenges to applying the IRIS domestic violence model to other patient groups have been highlighted by the IRIS+ study in our recent paper published in BMC Family Practice. The study found that despite increased preparedness reported by GPs and practice nurses after the IRIS+ training in managing a wide range of domestic abuse cases, there were barriers to identifying and referring men and directly referring children (without their non-abusive parent) to a specialist domestic abuse service.
The rate of referral of women survivors of domestic abuse in the study period was comparable to the original IRIS trial. The IRIS+ service also received a substantial number of child referrals alongside their non-abusive parent. The study shows that clinicians are successfully addressing the needs of female survivors and have the knowledge and skills to respond to the needs of all patients affected by domestic abuse. They are, however, not converting these relevant skillsets into practice responses to other patient groups, particularly men presenting in general practice.
We know from the implementation of IRIS that the normalisation of practice responses to female survivors requires repeated training, sustained system-level support and time. Allowing ample time for embedding a step-change in asking men and children directly may be needed for connecting with other family members. The study reveals specific alterations that might be required to achieve identification and referral of men and children in primary care: an enhanced focus on engagement with men, direct engagement with children, and improved guidance and training on responding to reports of domestic abuse received from other agencies.
Balance between flexibility and rigour
The development and testing of IRIS+ represents an important step towards broadening our understanding of the potential of training and support interventions in primary care settings to adults who are experiencing or perpetrating domestic abuse and their children. It also highlights the value of feasibility work in establishing the relevance and viability of modified interventions even when they are based on adapted versions of well-established programmes which have evidence of effectiveness in their original form. In a world of evolving complex interventions and rapidly tweaked implementation, decisions on when and how to evaluate adapted designs can have implications for the future of interventions and the outcome of patients.
A journey towards feasibility
The IRIS+ journey from development to rigorous evaluation towards a model that works outside current clinical comfort zones continues. The study team is currently testing the acceptability and feasibility of a reconfigured intervention developed from the findings. The revised IRIS+ training and support programme has an enhanced focus on direct engagement with children and young people experiencing domestic abuse. It also has an increased emphasis on addressing the specific needs of affected male patients (victims and perpetrators) representing different types of masculinity and sexuality and improved guidance on responding to domestic abuse information received from other agencies.
Early findings of the second stage of the IRIS+ study, which is also exploring the impact of COVID-19 on domestic abuse general practice referrals and patient support, indicate that the reconfigured IRIS+ intervention is viable in safely and effectively supporting the needs of a broader spectrum of patients, including male victims, children and young people. The feasibility, acceptability, effectiveness and cost-effectiveness of the reconfigured IRIS+ training and advocacy support programme is currently being fully evaluated across two areas in England and Wales.
Paper: Szilassy, E., Roy, J., Williamson, E., Pitt, K., Man, MS., Feder, G. Reaching everyone in general practice? Feasibility of an integrated domestic violence training and support intervention in primary care. BMC Family Practice, (2021) 22:19
Disclaimer: IRIS+ is part of the REPROVIDE programme (Reaching Everyone Programme of Research On Violence in diverse Domestic Environments), an independent research programme funded by the National Institute for Health Research (Programme Grants for Applied Research), (RP-PG-0614-20012). The views expressed in this publication are those of the authors and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care.
This article was originally published under the title: ‘Supporting men and children experiencing domestic violence through general practice’ in GP Online (25 January 2021).