Characteristics of survivors accessing hospital IDVA services
Table 1 presents the demographic characteristics of survivors at the point of
accessing hospital IDVA services (T1) compared to those working with community IDVA services. Most survivors supported by both services were white British or Irish (84.2% hospital; 77.5% community), heterosexual (98.0% hospital; 90.2% community) women (93.6% hospital; 96.2% community) who were, on average, in their mid-thirties (M = 35.6, 95% CI 34.6 to 35.4; hospital; M = 34.9, 95% CI 34.5 to 35.3 community). In both settings, smaller numbers of black, Asian, minority and ethnic groups (BAME) (15.3% hospital; 17.1% community), men (5.1% hospital; 4.2% community) and lesbian, gay, bisexual or transgender (LGBT) (2.0% hospital; 2.2% community) survivors were identified. Survivors working with hospital IDVAs were more likely to be pregnant (17.1% hospital; 6.3% community) or not have children at home (51.1% hospital; 67.2% community). A higher proportion of hospital survivors were aged over fifty-five (10.1% hospital; 6.8% community) and came from higher-income households (salaries over £36,400 per annum) (9.1% hospital; 4.2% community). Hospital survivors reported higher levels of complex needs and additional vulnerabilities including mental health difficulties (57.3% hospital; 35.2% community), alcohol (18.4% hospital; 8.3% community) and drug use problems (11.2% hospital; 5.2% community), financial difficulties (40.1%; hospital; 30.3% community) and disability (12.2% hospital; 8.3% community). Twice as many hospital survivors had ever planned or attempted suicide (36.3% hospital; 16.2% community) or had self-harmed (43.5% hospital; 23.5% community).
In the three months before accessing IDVA services, survivors in both settings experienced a high level of severe physical abuse (46.6% hospital; 41.2% community), jealous controlling and coercive behaviours (47.3%; hospital; 47.1% community) and harassment or stalking (30.8% hospital; 34.1% community). For all survivors, this abuse had escalated in severity and frequency within the last three months (57.2% hospital; 68.3% community). For community IDVA services, this escalation was higher and community IDVAs were more likely to deem their cases at higher risk of serious harm or fatality from the abuse (53.1% hospital; 58.2% community). However, hospital survivors were more likely to report severe forms of sexual abuse in the previous three months (14.3% hospital; 10.2% community). At the point of engaging with hospital IDVA services, survivors had experienced abuse for shorter periods (Mdn = 30.0, IQR 60.1) compared with community services (Mdn = 36.3, IQR 70.0).
Community IDVAs tended to support survivors who were experiencing abuse from an ex-partner (35.3% hospital; 59.7% community). Hospital survivors were more likely to experience abuse from a current intimate partner (53.4% hospital; 31.6% community) or multiple perpetrators (14.3% hospital; 8.3% community). Higher proportions of hospital survivors were living with the abuser at the point of referral (48.3% hospital; 29.7% community). Despite being more likely to have been abusive to other partners or family members (79.3% hospital; 67.7% community), those perpetrating abuse towards hospital survivors were less likely to have a criminal record for DVA (36.6% hospital; 45.2% community).
Identifying and referring survivors of domestic abuse across healthcare settings
Table 2 presents the help-seeking behaviours reported by hospital survivors
compared with community survivors in the six months preceding support from an IDVA service. Those working with community IDVA services were more likely to have called the police (77.2%) than those supported by a hospital IDVA (58.7%); whereas, hospital survivors had accessed a greater number of health services for issues specifically related to DVA. They were more likely to have visited their GP (88.3% hospital; 77.2% community) and ED (56.2% hospital; 16% community). More hospital survivors had attended ED by ambulance (37.3% hospital; 16.3% community) than community survivors. Around a half (45.7%) of survivors identified by hospital IDVA services had done so after an overdose or because of mental ill health (50.6%); while 13.4% had visited ED because of physical injuries from the abuser.
Analysis of referral routes into the hospital IDVA service (Table 3) show that
84.6% of cases came from other health services, mostly within the hospital itself. ED played a key role in identifying survivors, accounting for over half (62.3%) of hospital IDVA referrals, followed by maternity and ante/neonatal units (16.8%) and psychiatry or mental health departments (7.3%). Nurses identified the greatest number of survivors (45.6%), followed by consultants/doctors/junior doctors (18.2%), midwives (13.7%) and psychiatrists/psychologists (8.4%). Comparatively, in community IDVA services, referrals were less likely to come from health services (2.3%). At the point of exiting the service, hospital IDVAs had helped survivors to access a higher number of health-based services than community IDVAs (Table 4).
Hospital survivors were more likely to have been referred to mental health services (22.9% hospital; 14.9%) and substance services (34.0% hospital; 3.3% community); whereas, community IDVAs referred higher proportions of survivors to the police (52.1% hospital; 83.7%).
Length and type of support
Support provided by hospital IDVAs (Table 5) comprised regular contact and
access to a number of community programmes and resources. On average, hospital survivors were supported for just under two months (months Mdn = 1.7, IQR 2.7) which was shorter than support at community services (months Mdn = 2.4, IQR 3.1). However, hospital IDVAs worked as intensively as community IDVAs over this period with both services delivering the same number of face-to-face contacts with survivors (Mdn = 8.0 both hospital and community). Both IDVA services were most likely to provide support around safety planning, health and wellbeing, the police and housing. Survivors working with hospital IDVAs were more likely to have been helped to access safety planning (72.3% hospital; 63.4% community), health and wellbeing services (67.7% hospital; 56.3% community), the police (47.8% hospital; 41.2% community) and housing (45.3% hospital; 31.4% community). Hospital survivors were less likely than community IDVA survivors to have been helped to access civil orders (5.2% hospital; 14.3% community) or support with the criminal courts (1.1% hospital; 4.4% community).
Health measures at the point of accessing a service (T1) demonstrated that hospital IDVAs worked with survivors who reported poorer physical health (T1 M = 49.2, 95% CI 47.1 to 53.9) and substantially poorer mental health (T1 M = 32.3, 95% CI 29.5 to 34.2) compared with the general UK population (Table 6). Among hospital
survivors, levels of anxiety (T1 M = 12.2, 95% CI 10.6 to 13.5) and depression (T1 M = 10.5, 95% CI 7.9 to 12.2) were twice the national average. At T1, over half (62.6%) screened positive for Post-Traumatic Stress Disorder (PTSD) (T1 M = 2.1, 95% CI 1.7 to 2.5). Between T1 and T2 (three months after exiting support for DVA), no changes were observed in health outcomes among hospital survivors. While survivors reported a lower level of physical (T2 M = 48.7, 95% CI 45.9 to 54.0) and mental health concerns at T2 (T2 M = 39.6, 95% CI 34.9 to 44.3), specifically around anxiety (T2 M = 11.4, 95% CI 10.6 to 12.6), depression (T2 M = 8.6, 95% CI 7.9 to 10.0) and PTSD symptomology (T2 M = 2.0, 95% CI 1.4 to 2.6), no significant differences were observed; potentially owing to the small sample size.
Outcomes relating to the change in DVA assessed at the closure of cases revealed some positive changes in safety for survivors accessing both IDVA services (Table 7). Survivors accessing hospital IDVA services were more likely to experience
cessation of abuse at the point of exiting the service than survivors identified by community IDVA services (62.4% hospital; 48.3% community). Hospital survivors reported a higher level of reduction in physical abuse (86.2% hospital; 71.2% community), sexual abuse (82.4% hospital; 73.3% community), harassment and stalking (75.6% hospital; 52.4% community) and jealous coercive and controlling behaviours (70.1% hospital; 52.2% community) (Table 8). Hospital survivors were
more likely to report that they felt ‘much safer’ (54.2%) compared to survivors who accessed a community service (50.1%). Across both services, several survivors reported a continuation of abuse at exit. Abuse was ongoing in 10.2% of hospital IDVA cases and 18.4% of community IDVA cases.
Tables 9 and 10 presents the results of logistic regression analyses
- Insert tables 9 and 10 here -
examining the association between the different resources / programmes received and reported safety among survivors who accessed IDVA services, controlling for potentially confounding variables. Analyses showed that safety increased if the support provided was more intensive. Survivors who had accessed a hospital IDVA service were two times more likely to report feeling safer at case closure (AOR = 2.03, 95% CI 1.18 to 3.49) if they had received over five or more contacts with an IDVA. Similarly, survivors accessing the hospital IDVA service were found to have higher odds of achieving feelings of safety if they had been supported over a longer period and had accessed a higher number of resources / programmes provided by wider community services. Accessing six or more resources / programmes increased safety by one and a half times AOR = 2.38, 95% CI 1.41 to 3.87) and odds of achieving this outcome increased progressively with a greater number of support days provided by the IDVA (AOR = 2.00, 95% CI 1.00 to 1.01). Survivors who had accessed a hospital IDVA service were more likely to report no change or feeling less safe at exit if they had experienced suicidal ideation or behaviours at the point of initial referral (AOR = 2.00, 95% CI 0.28 to 0.74). The same model was applied to the community IDVA cases and findings were replicated, whereby, feelings of safety were increased in line with more intensive support in terms of more frequent contact with a community IDVA (AOR = 1.45, 95% CI 1.12 to 1.89) and access to a range of resources / programmes (AOR = 1.82, 95% CI = 1.43 to 2.31).
Health resource use and cost analysis
In the six months before accessing IDVA services, hospital survivors used more health services than community survivors (Table 11). In terms of single
components, differences were observed for general practices (hospital M = 4.9, 95% CI 3.7 to 6.0; community M = 2.6, 95% CI 1.8 to 3.9), mental health services (counsellors) (hospital M = 3.0, 95% CI 0.4 to 6.4; community M = 1.5, 95% CI 0.0 to 3.0), inpatient stays (hospital M = 3.6, 95% CI 1.2 to 6.0; community M = 0.3, 95% CI 0.0 to 0.7), ED attendance (hospital M = 1.0, 95% CI 0.6 to 1.3; community M = 0.4, 95% CI 0.1 to 0.5) and ambulance trips (hospital M = 0.6, 95% CI 0.3 to 0.1; community M = 0.2, 95% CI 0.0 to 0.3). The cost analysis based on health resource use showed that hospital survivors cost on average £2,248 (95% CI £1,646 to £2,977) and community survivors cost on average £533 (95% CI £373 to £713).
Based on the difference in resource use six months before (T1) and six months after (T2) accessing the hospital IDVA service, a cost reduction was observed post-intervention in most hospital services (Table 12). Hospital survivors
reported fewer inpatient stays (T1 M = 4.5, 95% CI 0.8 to 10.0; T2 M = 0.0), ED attendances (T1 M = 0.9, 95% CI 0.3 to 1.4; T2 M = 0.4, 95% CI 0.0 to 0.7) and ambulance trips (T1 M = 0.6, 95% CI 0.0 to 1.0; T2 M = 0.1, 95% CI 0.0 to 0.3). Outpatient appointments increased pre and post intervention (T1 M = 0.8, 95% CI 0.3 to 1.1; T2 M = 2.7, 95% CI 0.3 to 5.0). Decreased use of hospital services offset the increase in cost observed in slightly higher levels of attendance at general practices (T1 M = 4.0, 95% CI 2.5 to 5.8; T2 M = 5.3, 95% CI 3.4 to 7.2), mental health services (community psychiatric nurse) (T1 M = 4.0, 95% CI 2.5 to 5.8; T2 M = 5.3, 95% CI 3.4 to 7.2) and substance services (T1 M = 1.1, 95% CI 0.1 to 2.3; T2 M = 1.5, 95% CI 0.4 to 3.4). However, the only significant difference in health service use pre and post intervention was attributed to the decrease in hospital inpatient stays; potentially owing to the small sample size. Overall, the cost reduction post intervention was equivalent to savings of £2,076 per patient per year when the resource use is extrapolated to a one-year period (6 months £1,038, 95% CI £182 to £2,030).