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To the authors’ knowledge, this is the first study that explored public attitudes and perceptions concerning DVA, and the use of a short screening tool during routine touch points in community, health and social care settings in the UK.
Our findings highlighted that whereas all respondents were aware of the concept of abuse, people’s awareness of DVA may have increased somewhat due to the broad publicity it has received during the first national lockdown following the advent of COVID-19. This is supported by the world’s longest-running survey, The National Community Attitudes toward Violence against Women Survey, reporting the majority of Australians’ levels of awareness towards violence against women have generally risen [21]. Indeed, whereas CSEW estimated a DVA prevalence rate of approximately 5 in 100 adults in the year ending March 2021 [22], 18% of all the crimes recorded by the police during that same period were due to DVA incidents, equating to a rise of 6% from the previous year [22].
Just over a third of our study respondents reported having been exposed to or experienced some form of abuse. The main reason for non-disclosure was emphasised as the lack of public recognition attributed to normalisation or social silence with its associated fear, stigma and ‘lack of trust in the system’ at local and national levels. Our findings corroborate a recent UK study on South Asian women which revealed the numerous ways in which denial of citizenship continues even long after the end of the abusive relationship, and the efforts needed to regain a sense of identity, belongingness and membership within their intimate, family and community lives [23].
That only half of the participants in the study were aware of existing support services in the UK was consistent with previously published research confirming that DVA cases are vastly unreported [11]. Feedback from respondents also echoed the findings of a recent NHS survey which showed that two in five people were unsure or did not know where to get help after being abused, and more than half of people did not ultimately seek help following their experiences of abuse [24]. DVA organisations including The Survivors Trust and politicians are also attentive that many victims and survivors are unaware of the specialist support available to them and how to access it [24]. As one respondent states, this shows that the abuse recorded is only the ‘tip of the iceberg’ in the UK, largely because most victims may not access support for what some individuals deem to be a ‘private matter’.
Many of the interventions proposed by our study participants have already been implemented in the UK, reinforcing the significance of simultaneously raising public awareness and improving the visibility of accessible support mechanisms for both victims and perpetrators. A new campaign launched in February 2022, coinciding with the first day of UK’s Sexual Abuse and Sexual Violence Awareness Week, aims to raise awareness of the centres and support available in England to those experiencing sexual assault, abuse or rape, including those not knowing who or where to turn to [24]. This is an important step to help raise public awareness of DVA and is the largest such campaign in the UK since the advent of COVID-19.
Consistent with our findings, a recent study of DVA victims in rural communities in Southern Ontario recommended outreach programs and campaigns in supporting public and professional education [25]. Another study conducted on Chinese university students suggested that education plays a powerful factor in influencing perceptions and attitudes concerning DVA compared to factors such as gender, residence and age [26].
Prevention strategies using the socio-ecological model
The Centers for Disease Control and Prevention uses a four-level social-ecological model to analyse the interplay between individual, relationship, community and societal factors, to better understand violence and the effects of potential prevention strategies [27]. Multi-level interventions are needed to sustain prevention efforts over time and achieve population-level impact. In our analysis, we used the socio-ecological model as a framework [19] to illustrate how the respondents’ recommended prevention strategies could be used to tackle DVA in our society (Table 3). This approach sheds light on how dynamic interactions across multiple domains ranging from individual risk factors to broad social factors could contribute towards the risk and protective elements for DVA [9]. It also highlights how preventive interventions can be developed to work across four distinct levels: individual, relationship, community and societal.
As there can be no ‘one size fits all’ approach to tackling DVA, the socio-ecological lens reinforces the importance of developing a comprehensive approach in which actions at each level of the social ecology synergise with interventions implemented at other levels [19]. Similar approaches have been utilised in other DVA studies proposing potential prevention strategies, practice and policy implications [28]. Multi-level programs are most effective in changing behaviour, but there is consensus that any such interventions need to be funded and sustained for several years to make any real impact on the actual cases of DVA.
At the individual (micro) level, raising awareness educates and influences people to change their attitudes, behaviours and beliefs, thus helping to shift public opinion and sway the political will of decision-makers [29]. At the relationship and community (meso and macro) level, public education campaigns focussing on the individual’s social responsibility in the community may also help change some of the prevailing and largely unhelpful societal attitudes towards DVA such as victim-blaming, silence, tolerance, stigma and inhibition, and could make a substantial contribution to preventing abuse [30].
It is widely acknowledged that social support leads to positive mental health outcomes, improved quality of life and more willingness to seek formal support and physical safety [17, 31]. Having open dialogues about the detrimental health consequences of abuse in society, coupled with more awareness about appropriate referral pathways and linkage with local support services, including helplines might motivate survivors to pursue support. This mobilization could also prompt support networks to encourage those who are ignorant or inhibited due to social silence to come forward. By breaking this ‘deafening code of silence’ and reducing social tolerance and inhibition, individuals, health systems and society can take the necessary steps towards the challenge of ‘melting the iceberg’ of DVA. This could also help raise awareness among perpetrators who may become more accepting of receiving support [32].
Routine use of screening tools
Assessment tools and guidelines are available to help promote the recognition of and outline the support available to people experiencing DVA [33, 34]. Studies have shown that routine DVA screening improves victim identification in healthcare settings [32], playing a key mechanism in reaching and supporting the victims, particularly those who may not engage with other services. Currently, the National Institute for Health and Care Excellence (NICE) in England does not recommend the use of validated tools for routine screening of DVA [35]. The US is one of the few countries with a policy of screening for DVA, but some of the evidence for screening in healthcare settings is contraindicatory [36]. For example, there are no head-to-head trials of screening versus clinical enquiry, and we do not know which is more effective. Nevertheless, screening programmes are not all that different from targeted inquiry approaches [36]. Thus, whereas our study findings also highlight that routine screening can be an effective means for early identification of victims, other studies showed that many doctors do not implement screening because of time constraints, lack of training or discomfort with asking about abuse [36] which was reiterated by our study HCPs.
Any contact between the patient and the healthcare system offers a window of opportunity to diagnose abuse or neglect [37]. Routine enquiry of DVA, even when there are no obvious indicators of abuse could assist in early identification, raising public awareness and tackling the issue before it escalates. Our study findings suggest that routine touchpoints with HCPs in the NHS and social care settings to be an ideal opportunity to identify those experiencing abuse. Asking all patients standard questions can help with this and at the same time highlight to victims that they are not alone in their experiences. Additionally, this may even prompt perpetrators of abuse to recognise and seek support. Examples of brief screening tools for DVA include the Woman Abuse Screening Tool (WAST), WAST-Short, and Hurt-Insult-Threaten-Scream (HITS) tool [38,39,40]. In this regard, HCPs have a crucial role in tackling DVA, especially when utilising rapid assessment tools to identify abuse, when signposting to suitable services or when helping promote the recognition of and outline the support available to victims [34, 41].
Rationale for using routine touchpoints with health and social care to screen for DVA
The working age (16–65 years) population of the UK consists of 34.4 million individuals [42], equating to 51.3% of the total UK population which was 67 million in 2020 [43]. The NHS workforce alone comprises of 1.4 million individuals [44], whereas the social care workforce is 1.54 million [45]. Combined, the health and social care (H&SC) workforce comprises of 2.94 million individuals, equating to 8.6% of the total working population. The UK’s large H&SC workforce routinely engages with the vast majority of the total UK population on an annual basis (i.e., during touchpoints with a HCP, GP, specialists in secondary care, or allied health professionals for reablement or social care), which makes it ideally suited to raise awareness and screen for DVA using short, validated tools. The provision of on-going training and support to the H&SC workforce is necessary to improve the professionals’ confidence in the identification, guidance, and referral of victims to the existing DVA support services. It is crucial to increase access to effective screening tools in order to make it easier for HCPs to assist victims in disclosing information about DVA so that the root cause could be addressed. As screening plays a central role in the early identification of DVA, particularly unreported and easily hidden abuse (e.g., psychological, financial, coercive, and controlling behaviour), we recommend that the routine use of validated screening tools for DVA be considered by community and NHS primary care services to promote the timely identification of victims for signposting and referral to appropriate support services.
Education and training
Rapid screening for DVA during routine H&SC touchpoints should be supported by structured education and training in the school setting. Most respondents proposed that a DVA awareness exercise should ideally be integrated into the school curriculum, and to feature as part of the education workforce induction and mandatory training, but this is unlikely to happen at scale without the support from policymakers. Entertainment venues also have a momentous role in educating the community, via creative interaction and by providing a safe place for victims to seek help.
‘Everyone has a role in ending domestic abuse; together we can create a society that no longer tolerates abuse’ (F20)
Serious case review findings show that death or serious harm might have been prevented if H&SC professionals had acted upon their concerns or sought more information [46]. This makes the case for more pervasive use of short DVA screening tools (e.g., WAST-Short), and those multiple strategies to tackle DVA throughout the life course are needed with consistent funding and support from policymakers.
In summary, raising public awareness, enhanced education and training of people from all walks of life and throughout the life course coupled to the routine utilisation of screening tools for early identification of DVA can help tackle this ‘wicked’ problem of society. Collaborative efforts from every layer of society and organisations including schools, communities, workplaces, healthcare settings, law enforcement bodies and politicians are required to keep DVA ‘relevant’ via public awareness campaigns to affect a positive change in social attitudes and the visibility of support services.
Study limitations
Because our study sample was small and from a localised area, the findings of our study are not necessarily representative of the UK population. Nevertheless, useful insights into personal experiences were provided by this small cross-section of respondents. In qualitative studies, the pragmatic sample size is often considered sufficient when saturation of themes is nearly accomplished [47]. We feel our data was sufficient in this respect. We acknowledge that additional interviews may have resulted in the identification of other emergent themes, particularly with respect to considering the perspective of perpetrators and not just individuals who may have suffered abuse. Inevitably, the study sample included some selection bias [48], such that only those with an interest or who experienced DVA, or those who were in employment or highly educated participated in the interview, but the breadth of contextual data we explored was adequate given the sensitive nature of the topic. A larger study with a more diverse cross-section of British society is indicated, including data collection from the health and social care workforce, policy makers and commissioners of wellbeing support services.
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