Early detection and intervention

Domestic violence is a very serious crime. Statistics show that 2,350 women have sought the services of Social Welfare Development Programme since it was set up in 1994 and of Appogg (2001) - 300 women every year.

The prevention of violence against women and children is a social and political issue, calling for an integrated and comprehensive strategy based on the three Ps: active prevention of crimes of violence against women and children; adequate provision of support services and appropriate legal protection for women and children who are victims of violence.

The police, the criminal justice system and social services, probation and the voluntary sector play a significant role in dealing with the problem of domestic violence but we can best tackle the crime through a multi-agency, multi-disciplinary approach, one that is rooted in early intervention. There is need to build on this approach and to recognise that there are specific areas where a targeted and focused response is required. The health service is one of them.

Why the health service? The health service has a particular contribution to make. Domestic violence affects health, both physical and mental, and so the health service may offer the best contact point with staff that can recognise domestic violence and help those affected by it.

Those at the receiving end of domestic violence are more likely to suffer poor health, chronic pain, depression and be subject to suicide attempts. They are seen by health professionals in routine services. Domestic violence in pregnancy has been associated with foetal distress, poor pregnancy outcome, low birth weight and pre-term labour.

How can the health service help? Health service professionals should be able to recognise when abuse is occurring and to understand that for good reasons the woman is often reluctant to talk about it. In fact, she may be completely unable to talk about it.

Even though they consult their GP, they conceal their experience of domestic violence. There are very good reasons for this - shame, stigma, fear, fear that their partner might find out that they have told someone or fear that their children may be taken into care or the doctor, nurse, midwife, health professional may seem in a hurry, uninterested, unsympathetic and occasionally even hostile.

They may feel embarrassed; the health professional may seem awkward, ill-informed and out of their depth.

It is clear that if health professionals are to offer services which women who experience domestic violence need, and are entitled to expect, the staff must have greater understanding of the issues and the competence and the confidence to take appropriate action.

If we do not identify domestic violence, we are failing some of those who are most vulnerable in our community, women and children. The health professional that intervenes without understanding the complexity of the issues can in fact place the woman at greater risk.

The focus is clearly on women, but we realise that where there is domestic violence against women, there may also be abuse towards children and vulnerable adults in the family.

Health professionals should be prepared to ask questions, moving from the general to the more specific. Certain injuries should trigger concern, for example, injuries on the face and hands, abdominal injuries and multiple and recurrent injuries.

Health professional should be able to take the necessary action, believing the woman and responding to her immediate problems, assessing further risk to her and to her children, if she has children, keeping care records and providing information.

In most cases, it is information that women need, not advice. They would also have to ensure continuing support and follow-up. Appropriate action should not only deal with the immediate problems the woman is facing but, also, with work connected with the provision of evidence for a criminal justice intervention and prevention of repeat abuse to the woman herself or her children.

We need to create a culture which takes collective responsibility for tackling domestic violence rather than hoping that someone else will do what needs to be done.

In maternity services and primary care, we have opportunities to establish a relationship of trust with women. In other places, such as the emergency department, staff must be trained to respond to an immediate crisis. Protocols and referral processes should be in place and staff trained and supported in their use.

This is particularly important as other initiatives which the government is taking will make it more likely for women to seek help from health professionals. For the strategy to succeed, however, training is essential.

It can be very damaging if, for example, a midwife asks a question and does not understand why a woman answers in a particular manner rather than in another.

Professional training also enhances the support that health professionals can give within their own community, social and family groups.

We also need to improve the data gathering systems to enable information on domestic violence to be analysed and shared. If we are to begin to plan local services better, we must be able to describe current services, detail how these services are being used and by whom and identify ways in which we need to improve them.

Health promotion plays an important role as a mass media education campaign raises awareness of the extent and nature of crimes of violence against women and also looks at why these crimes happen.

Campaign material should include pictures of positive images of women and children. A health promotion mass media campaign should promote health in its broadest sense, that is, by promoting the prevention of many health consequences of domestic violence: homicide, serious injuries, injuries during pregnancy, injuries to children, unwanted or early pregnancies, STD, including HIV and AIDS.

There are also the psychological consequences, including suicide, mental health problems and the effects on children of witnessing violence.

Finally, there are societal consequences, for example, added health care costs and the effects on productivity and employment.

It is not easy to introduce a social health care model into a hospital setting. This means a whole change of culture within the medical profession, especially within the hospital setting where a change from a medical model of health care to a social model is necessary.

I hope that this quotation from a resource manual will make us all realise the urgency with which we need to move forward.

"I wish I had been asked about what had happened, I was so ashamed, but I really wanted to tell them, they did not ask me though and I did not have the courage to tell them myself. Even though he was not there I lied for him just like I always did. They just gave me some pain killers and sent me home."

Ms Attard is president of the National Council of Women.