Feature

When home is where the hurt is

Domestic violence is a major threat to the health of women and children — and it’s time for a national strategy to address it, argues Annie Moelwyn-Hughes

The health of thousands of women and children in the UK is at risk as a result of domestic violence. In Scotland alone it is estimated that as many as 250,000 to 700,000 women — almost a third of the adult female population — may be experiencing domestic violence, defined as ‘psychological, emotional and economic as well as physical and sexual abuse of women by male partners, or ex-partners’.

The problem of domestic violence has been well documented over the last 20 years. Research has provided clear evidence of its nature and extent, of the impact of domestic violence on women and children, and of the difficulties women face in getting the help they need. There is evidence that domestic violence causes injury, ill health and major social disruption, as well as long-term psychological problems for many women and children. Both Women’s Aid and the Zero Tolerance campaign have consistently raised awareness of the problem.

But despite this, there is no national policy to guide local agencies and no requirement to provide support or services for women who experience abuse. Few local statutory organisations have developed an effective response to tackle the problem, to provide the services so badly needed by women (and their children) who have been abused and to prevent violence. In many of the areas where inter-agency strategies have been developed the involvement of health authorities has been lacking.

In 1995 the last government issued a circular intended to encourage co-operation between local agencies working to tackle the problems associated with domestic violence.¹ But the circular did not go far enough, and nor did it address the specific needs of women and children and how they might be met.

In his 1996 public health report the Chief Medical Officer, Kenneth Calman, recognised the Department of Health’s responsibility for the health and social care dimension of domestic violence.² He noted that some professional bodies in the NHS were identifying the extent of the problem and developing programmes to support their members in working with women who had been abused. The way in which these professional groups are developing their programmes and the extent to which they will ultimately reflect needs and preferences of women who have experienced violence is not clear. Neither is there a clear indication of the role that the DoH itself will play.

There is a danger here of developing ad hoc responses to domestic violence which are not part of an agreed national framework. Our response to domestic violence must be systematic across departments and agencies in order to be effective, and it must be based on the expressed needs of women and children themselves. Unless domestic violence is seen as a priority public health issue, it will not be given the attention and resources required to develop effective policy and practice.

There are three guiding principles which should underpin the development of domestic violence policy and practice in the health service. First, the safety of women and children is the prime consideration. Second, an awareness and understanding of the needs of women who have experienced domestic violence must be the starting point of all policy and practice. And finally, effective responses to domestic violence require a shift from a medical model to focusing on the health and social needs of women and children.

Two recent reports published in Scotland have called for action to address the problem of domestic violence. They set out a clear framework for developing a comprehensive approach at both local and national levels.

Action for change is a comprehensive multi-agency strategy for tackling domestic violence at a local level.³ The strategy was developed and agreed with representatives of Forth Valley health board, Central Scotland Police, local authorities and women’s aid groups of Falkirk, Clackmannan and Stirling. The common approach it advocates has now been adopted by all those organisations.

It is based on the view that domestic violence is a complex issue and those who experience abuse find it difficult to seek and to obtain assistance. Women who experience domestic violence may require a range of services: the NHS, women’s aid, local authority services, voluntary organisations, the police, solicitors and the courts.

The strategy also recognises that responding to domestic violence can be difficult for practitioners in the health service as well as in other agencies. It is important that the relevant organisations offer the information and support needed to enable their staff to provide the service that women want. This should include an explicit agency policy and guidance on core aspects of provision including: how to identify needs and intervene; guidance on co-ordinating multi-agency work; staff training and development; systems for recording and monitoring; information about the range of services available in the area; and emphasis on involving women in the planning, development and evaluation of services.

Domestic violence, published by the Scottish Needs Assessment Programme (SNAP) under the auspices of the Scottish Forum for Public Health Medicine, is a comprehensive review of domestic violence as a public health issue.⁴ Its aims are to provide an understanding of the meaning and nature of domestic violence, to define domestic violence as a public health issue by assessing current information on prevalence, health implications and use of health services, to determine the potential for health gain, and to make recommendations to commissioners and providers of health care.

The report makes clear that for many women domestic violence is a serious health risk. Women who suffer domestic violence are more likely to experience poor health, chronic pain problems, depression, high levels of anxiety and fear, addictions, difficulties in pregnancy and suicide attempts than women who do not. These health problems are the results, not the causes, of abuse. And the report cites the shocking statistic that half of all women victims of homicide in Scotland are killed by their partners.

The profound effect of domestic violence on children is also highlighted in the report. The range of emotional difficulties identified among children of mothers experiencing domestic violence include increased levels of anxiety, psychosomatic illness, depression, withdrawal, fear, and serious disruption to their education. As well as the indirect impact of domestic violence on children, there is evidence to link perpetrators of domestic violence with direct physical and sexual abuse of children in the same family.

Studies of women’s experiences of health services suggest that services are often failing to respond sensitively and appropriately. Neither GPs nor health visitors appear to reliably recognise the signs and symptoms of domestic violence. Many women have their injuries treated in A&E departments without the violence which caused the injuries being questioned.

In the light of the alarming evidence on the prevalence and impact of domestic violence, it is hard to understand why it is not seen as a public health priority in the UK. By contrast, in Canada and the US domestic violence is recognised as much as a public health problem as a civil or criminal justice issue. The sooner that we come to see this in the UK, the sooner we can begin to ensure that the needs of abused women and their children are being met, and that all possible efforts are being made to prevent such abuse in the first place.