Identifying Domestic Violence (DV) and sexual assault (SA) presentations and referral pathways at John Hunter Hospital Emergency Department: comparative analysis of DV and SA cases


 Background: There are a number of negative and often long-term mental and physical health consequences of Domestic violence (DV) and Sexual assault (SA). Women experiencing DV and SA visit their health care professional more frequently than women not experiencing these abuses. Health care professionals in any health care settings can play crucial roles in identifying, managing and preventing DV and SA. In particular, those who work in emergency departments (EDs) are in a unique position to identify patients and initiate early interventions as they are often the first point of contact to access help. Methods: This is a retrospective observational cross-sectional study. Data was extracted from the site ED electronic information system (ipm) for all eligible females (alleged assault) who presented within the study period. Statistical analyses were programmed using SAS v9.4 (SAS Institute, Cary, North Carolina, USA). All data were checked for completeness and discrepancies before analysis. Descriptive statistics are reported for all relevant variables. The Hosmer-Lemeshow goodness of fit test was used to determine the adequacy of fit between the final model and the data. Results: Study findings indicate the high level of mental health issues among women presenting with both DV and SA. More than half of the victims had recurrent presentations to ED. The majority of victims were referred to the related support services within hospital or external services. Most of injuries in the sample were sever physical injuries. Conclusions: As the first point of contact, ED health professionals have a crucial role to identify and respond to SA and DV cases. If identified early, the recurrent admissions can be prevented and any early intervention can have a positive benefit for the longer-term health of the DV and SA victims. It can also save health care system spending. The development of a DV/SA flowchart for identification of these cases in ED as well as a clear referral pathway and ideally mandatory DV routine screening at EDs in all hospitals would be some practical strategies for achieving early intervention. Keywords: Domestic Violence, Sexual assault, Emergency Department, Domestic Violence screening, recurrent presentations


Background
Domestic violence (DV) is a violation of human rights that disproportionately affects women. This is a serious, but preventable public health problem that is common worldwide. It is estimated that globally one woman in every three (35%) has experienced physical and/or sexual violence at some point in their lives (WHO, 2016). The 2016 Australian Bureau of Statistics Personal Safety Survey (ABS, 2017) shows that one in 6 Australian women has been subjected, since the age of 15, to physical and/or sexual violence by a current or previous cohabiting partner. Family, domestic and sexual violence happens repeatedly-more than half (54%) of the women who have experienced current partner violence, experience more than one violent incident (ABS, 2017). One woman a week is killed by a current or former partner in Australia (Bryant and Bricknell, 2017). Furthermore, sexual assault can occur in the context of domestic and family violence (up to 40%) (NSW Government, 2019).
It can be a tactic of DV and should not be considered a separate phenomenon. Victims of sexual violence are also less likely to seek help than victims of other kinds of domestic violence (2019). For victims, there are a number of negative and often long-term mental and physical health consequences of different forms of domestic violence. Long-term physical health consequences of DV are intensely connected to long-term mental health consequences (Shen and Kusunoki, 2019).Victims of DV report higher rates of a range of health issues than non-victims (WHO, 2017;Ayre et al., 2016).Women experiencing DV visit their health care professional more frequently than women not experiencing DV (Gass et al., 2010;Rivara et al., 2007;Sprague et al., 2016). While there are important damaging effects on health for any kind of abuse (sexual, physical, psychological and emotional abuse, or neglect), health consequences may be worse for victims experiencing numerous forms of abuse co-occurring or combined over a lifetime (Laing, 2018;Taft, 2003;WHO, 2002).
Generally, health services provide a unique opportunity to identify women subjected to violence, provide them with appropriate care, connect them to other support services and, potentially, contribute to preventing future harm. For those who do seek professional help for violence, health-care providers are often women's first and most trusted point of professional contact (WHO, 2017). Health care professionals in any healthcare settings can play crucial roles in identifying, managing and preventing domestic violence (National Institute for Health and Care Excellence (NICE) 2014 ), but those who work in emergency departments (EDs) may regularly encounter people who have experienced IPV (Intimate Partner Violence), who tend to present with injury or non-injury-related complaints (Houry et al., 2008). ED clinicians are therefore in a unique position to ask patients about DV and initiate early interventions (Ali et al., 2016), as most women are hesitant to disclose DV, particularly when they are not asked directly (Morse, et. al, 2012;Irwin and Waugh, 2001). Nurses and other ED healthcare professionals must be able to distinguish between injuries resulting from DV and those from other causes, and provide patient-centred, sensitive and empathetic care to the patients involved. The failure to recognise DV in ED fails women as they are also not provided with correct care and, consequently, best practice is not followed. The issues faced by women as a result of not being identified as a DV victim include continued risk, recurrent ED presentations which usually escalate over time. However, there is evidence that failure to recognise or respond to DV in ED is due in part to the ED clinician not seeing this as central to their role (Boursnell and Prosser, 2010).

Domestic Violence Routine Screening
Globally, DV Routine Screening has been introduced in some health systems for early identification of DV as well as to improve the quality of healthcare. The screening uses a standardised set of questions, irrespective of the presenting reason (García-Moreno et al., 2015;Hunter et al., 2017). The implementation of routine screening is a low-cost measure and provides an opportunity for identification and early intervention for women experiencing domestic violence (O'Doherty et.al, 2015;Spangaro and Ruane, 2014;WHO, 2013). Most states in Australia have introduced antenatal DV screening (Australian Institute of Health and Welfare, 2015), while New South Wales (NSW) also conducts screening in early childhood, mental health and substance abuse programmes (NSW Ministry of Health, 2016a). However, EDs do not systematically screen for IPV in Australia (Spangaro et al, 2020 Health, 2006) formalised this strategy and requires screening to be undertaken in four target services as part of routine assessment. In accordance with NSW Health policy, and guided by the privacy principles outlined in Schedule 1 of the Health Records and Information Privacy Act 2002 (NSW), the NSW Police force may be notified if the woman wishes and/or where there are concerns for the safety of the woman and/or her children. In all other cases where DV is identified but referral to the NSW Police or Department of Communities and Justice (DCJ) is not necessary, the referral pathway is guided by the woman's preferences and needs. Health workers will refer women to relevant health services or to services outside the health system.

Nonetheless, the NSW Health Policy and Procedures for Identifying and Responding to
Domestic Violence does not require routine screening in the ED (NSW Department of Health, 2006). This is concerning, as many victims of DV, ED is the first point of contact to access help (Dawson et.al, 2019). Prevalence of DV is higher among ED users than the general population and those in most other healthcare settings (Sprague et al., 2014, Spangaro et al., 2020.
It is important to note that rates of routine inquiry about exposure to DV are reported as very low in emergency settings, ranging from 2% to 13%. A study by Webster et al. (2012) identified 12% of women attending ED did so as a result of an acute episode of DV, but less than one in seven of these women were asked about exposure to violence (Webster et.al, 2012  , population groups at higher risk of domestic and family violence are: Aboriginal people, people with disability, the lesbian, gay, bisexual, transgender, intersex and queer communities, people from culturally and linguistically diverse backgrounds, children, older women and people living in rural and remote areas. They need to be identified early and supported. Therefore, this study is significant as it will identify the number and characteristics of women presenting with DV and SA. This will assist health professionals with early intervention by improving referral pathways and, ultimately, result in a better quality of care for all.

Study aim
This is a retrospective observational cross-sectional study. The aim of the study is to identify DV and SA presentations to the ED of a large metropolitan tertiary referral hospital in NSW, Australia for a period of one year. It provides a description of the characteristics of all females who presented to ED with alleged assault.
The following questions are addressed in this project:  What is the prevalence of DV and SA presentations to ED?
 Are recurrent presentations identified in the data?
 What are the main characteristics of the presentations? For example, age, country of birth, being pregnant, having children, alcohol and drug abuse and mental health of the victim.
 What was the ED staff response to the cases? Were any referrals made to police, social workers, the child wellbeing unit or other support services?
 Is there any significant differences between DV and SA cases in terms of quantity and quality of referrals?

Participants and setting
John Hunter Hospital is the major trauma and teaching hospital for Hunter New England Health, NSW Health. It is located in Newcastle, NSW and is one of the busiest hospitals in NSW with between 18,000 to 22,000 ED presentations annually (Australian Institute of Health and Welfare, 2020).
The selection criteria is all females (no age limit) presenting with alleged assault to the ED at The variables mental health, having children and referral were re-categorised as yes/no indicator variables. The variable 'pregnancy' was also re-defined as yes for females who were pregnant at the time of incident and no for non-pregnant females and termination/miscarriage for females who had the experience of miscarriage/termination. The variable 'age' was categorised as <18 (child), 18-65 (adult) and 65+ (elderly). Characteristics identified at an alpha level of 5% on the Wald Chi-squared test in the logistic regression were considered statistically significantly associated with females who experienced domestic violence versus sexual assault.
The Hosmer-Lemeshow goodness of fit test was used to determine the adequacy of fit between the final model and the data; with a p-value > 0.05 on this test being considered an indication of an adequate fit. The area under the roc curve (AUC) was used to assess the discrimination ability of the final model, with a value of 0.7 or more considered acceptable. The influence of possible outliers was also assessed.

Results
There were 258 females identified as presenting for an alleged assault at ED, 97 for general alleged assault 1 , 105 for SA and 56 for due to DV. For the purpose of this study, only females who experienced DV and SA were included in the analyses. There is a possibility that some cases of alleged general assault might be domestic violence cases not disclosed by the victims.

Discussion
The current study retrospectively reviewed data pertaining to female patients who presented to a busy metropolitan ED in NSW, Australia, as a result of alleged assault. The cases were divided into DV and SA. It is noteworthy that there were 258 female alleged assault presentations to only one ED over a 12 months period, particularly, when we know most women are hesitant to disclose DV, unless they are specifically asked (Morse, et al., 2012;Irwin and Waugh, 2001). Furthermore, many of these cases were serious physical injuries which could not possibly be overlooked by health professionals due to their severity.
Therefore, this data does not show the true extent of the prevalence of DV and SA in EDs.
Study findings indicate the high level of mental health issues among women presenting with both DV and SA. This finding is in line with other research that provided evidence of the link between DV and anxiety and depressive disorder (Okuda et al., 2011;Suglia et al., 2011;Vos et al., 2006). The data clearly shows the pattern of referral made from the ED. Most of the SA and DV ED presentations were referred to the most relevant services. In particular, most of SA cases were referred to Hunter New England local sexual assault team and Child Wellbeing Unit child protection services and/or social workers. Although the referral rate is high and more than what is found in the current literature 2020), 27% of DV cases were not referred. We know that these women are likely to have future ED presentations and, considering the severity of DV cases, this is a concerning finding.
The study had a number of limitations including its retrospective nature, small numbers and single site making it ungeneralizable to other sites. Another important limitation was that no data were collected regarding the actual effectiveness of ED staff responses and referrals.
Furthermore, the research findings highlight areas where future research could be undertaken.

Conclusion
This study highlights the importance of gaining a more robust understanding of DV and SA prevalence and the characteristics of the women who present to our EDs having suffered DV or SA. This understanding is fundamental in facilitating appropriate prevention and early intervention to improve the health outcomes of these women. This is particularly relevant within ED settings, often the first point or sometimes last point of contact for many women who are victims of DV and SA. Whilst the specific results of this study are not generalizable, the findings will be of interest to other hospitals in different settings as they provide, for the first time, a description of DV presentations to ED, their characteristics, types of referral, staff responses, and impact on the future wellbeing of patients. What is clear from this study is the significant role of the health system in identifying and responding to the increasingly prevalent, damaging and costly problem of SA and DV. Despite the challenges of conducting research within this population, an emerging body of evidence points to the critical role of the health system in reducing the harms caused by SA and DV. In particular, the evidence points to investment in screening of selected vulnerable groups, training for first-line responders and expansion of interventions through an appropriate referral pathway and the essential role of social workers and enhancing their roles in the EDs. The long-term health costs arising from the epidemic of SA and DV mean that these are investments are likely to contribute to cost savings.