Empowering Sexual Health Clinicians: The ADViSE Programme for Addressing Domestic Violence and Abuse

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The connection between domestic and sexual violence and health is strikingly clear, as demonstrated by the following examples.

Women who have experienced domestic violence are (1): 

        + 2.3 times more likely to have issues with memory and concentration.
        + 87% more likely to complain of pain or discomfort.
        + 73% more likely to take pain medication.
        + 86% more likely to take medication for sleep.
        + 66% more likely to have been admitted to hospital for reasons other than labour.

Studies also suggest that childhood sexual abuse (CSA) has similar health impacts for male and female adult survivors (2). Interventions to identify and provide support via identification in healthcare settings are clearly needed. 

To address this need, the programme ADViSE (Assessing for Domestic Violence in Sexual Health Environments) was developed by IRISi (Identification and Referral to Improve Safety Interventions) to support staff in recognising and responding to patients affected by Domestic Violence (DV), Sexual Violence and Abuse, offering direct referrals to specialist services. IRISi is a pioneering social enterprise in the United Kingdom (UK) leading the development and implementation of evidence-based programmes to improve the healthcare response to gender-based violence.

ADViSE operates nationally throughout England including the capital London. The programme has received over 1100 referrals since its launch in 2021 following a successful 2015 pilot. Beyond the sheer volume of referrals, sexual health clinicians enrolled in the programme attest to its effectiveness: “The fact we can refer across such a range of issues: rape and domestic abuse but also grooming. And men as well as women. Previously I’d have suggested Rape Crisis or the Sexual Assault Referral Centre and said ‘take a photo of this number for the helpline’. Having ADViSE is completely different. It’s a person not a helpline and you feel so much more confident about encouraging someone.” The ADViSE Programme transforms Sexual Health Clinics by providing a ‘lifeline’ for patients who have experienced Domestic or Sexual Violence. Having moved from research into practice, IRISI’s newest intervention is making a difference to those affected by Domestic and Sexual Violence in Sexual Health.

The IRIS model has helped clinicians to identify, ask and refer over 36,000 patients and has been established as the “Gold Standard”, referenced in BASHH (British Association for Sexual Health and HIV) and recommended in Domestic Homicide Reviews. By harnessing the knowledge gained from this intervention, as well as adapting and honing for sexual health and sexual violence there is a real chance to offer patients more than they are currently receiving and bridge the gap between health and frontline DVA Services.  

IRISI’s vision is a world in which gender-based violence is consistently recognised and addressed as a health issue, and our mission is to improve the healthcare response to gender-based violence through health and specialist services working together. 

HOW ADVISE WORKS – AND WHY IT’S REACHING OUT TO A MORE DIVERSE RANGE OF PATIENTS? 

The National Institute for Health and Care Excellence (2014) standards around Domestic Violence state that clinicians should: (3)

        + know how to ask about DV

        + know how to respond to disclosures

        + refer survivors to specialist support services

        + refer perpetrators to specialist support services.

ADViSE meets all the above in one streamlined, evidence-based package. ADViSE does not replace existing services. It is established within the local service provision and so enhances and supports existing practice. It builds on these principles by recruiting and training an Advocate Educator, based at the partner organisation, who is an expert in Domestic Violence. Additionally, it involves recruiting and training a Clinical Lead, who will be based at the clinic where the intervention will take place. These two then deliver training to the rest of the clinicians blending their knowledge and expertise. Training is also offered to reception and admin teams who are often the eyes and ears of the clinics and can often see signs and behaviours before someone gets to the clinician.  

Anyone can be referred, regardless of their identity, the timing of the abuse or violence, or what they want to do. The ADViSE worker operates with a more flexible remit compared to traditional advocacy and support services. The support offered can be client led at the pace of the patient with no pressure to report or unsustainable timeframes. Being based at the clinic on certain days means that often a clinician can directly refer or offer for the AE to meet the patient then and there. AEs can also be based at specific clinics, this has worked really well in on ADViSE site with their Trans Clinic for example, by being present and building trust with patients and clinicians referrals are being made and support given: 

Across England, ADViSE has yielded significant insights from its Service Users*: 

        + 60% had not accessed support (of any kind around DV/SV) before.

        + 29% identified as LGBTIQ+.

        + 66% disclosed mental health issues (36% with a formal diagnosis).

        + 93% reported male perpetrators, highlighting the need for a gender-sensitive

           approach even when broadening access.

(*Data based on the Greater Manchester and Bristol and South Glos referral cohort over a year) 

We are proud of our inclusive programme and training and that we are reaching patients who have not accessed support before and with a high proportion – compared to other programmes – of LGBTIQ+ clients. We want to continue to work with marginalised groups and the single point of access really supports this intention. 

GROWTH, EVALUATION, AND FUTURE GOALS

We are pleased with how ADViSE has grown in the short time since its beginnings. We are in the process of evaluating the programme in two sites and will share the results once available. We have also recently been nominated for a National Health Service Parliamentary Award in the Health Equalities Category.

We want to trial ADViSE in different areas of the UK to understand how it works, but we, along with the sector as a whole, are facing difficult times. There have been significant cuts to front-line services which are having a profound effect on the lives of service users. Our intervention has costs to implement but we believe will save money and provide a return on investment in the long run. We would like to secure funding in order to prove this via an economic evaluation as well as to expand and offer our programme nationally and beyond.

The resounding feedback is that when ADViSE is embedded, it’s like it has always been there and it seems absurd to go back to what was or wasn’t there before. The model works – the Clinical Lead, the Advocate Educator, the training of clinicians and reception/admin staff and the co-located skilled DV workers provide additional support to those who might never have disclosed. Now that we have begun this work we need to continue to grow, evaluate and prove that just like with IRISi, our interventions are Gold Standard, invaluable and unique. We will strive to expand our work and ensure equity of access for patients. 

You can download the ADViSE Bite here.

MORE INFORMATION ON DOMESTIC VIOLENCE

If you are interested to learn more about domestic violence in the health sector, please visit our European training platform on domestic violence.

REFERENCES

(1) Potter et al (2020). Categories and health impacts of intimate partner violence in the World Health Organization multi-country study on women’s health and domestic violence. International journal of epidemiology, 1,11 

(2) Springer et al (2003). The long-term health outcomes of childhood abuse. An overview and a call to action. Journal of General Internal Medicine. 2003;18:864–870 

(3) National Institute for Health and Care Excellence (2014) Domestic violence and abuse: multi-agency working NICE guideline Available from https://www.nice.org.uk/guidance/ph50

Relevant Links: 

• https://irisi.org/about-the-advise-programme/  
• https://irisi.org/what-is-advise/

Relevant Aricles:

• Horwood et al (2018) Assessing for domestic violence in sexual health environments: a qualitative study Available from https://sti.bmj.com/content/94/2/88  
• Sohal et al (2018), Improving the healthcare response to domestic violence and abuse in sexual health clinics: feasibility study of a training, support and referral intervention Available from https://sti.bmj.com/content/sextrans/94/2/83.full.pdf  

ABOUT THE AUTHOR

Charlotte Chappell is Head of Programmes (ADViSE) at IRISi. Her main focus is to oversee the implementation and growth of the ADViSE programme. She holds a BSc in Sociology with Politics from the University of Plymouth and is a qualified IDVA. Charlotte has previously been a front-line service manager of Domestic Violence services and has a long history in the charitable sector. A freelance trainer specialising in Domestic Abuse and Safeguarding, she is also a Board Member for SARSAS (Somerset and Avon Rape and Sexual Abuse Support) a Magistrate, and is committed to seeing DVA as a health issue and ending gender-based violence.