Experiences of general practitioners in detecting domestic violence at General Practitioner Cooperatives: A qualitative study

Datum: 28-1-2013

Experiences of general practitioners in detecting domestic violence at General Practitioner Cooperatives: A qualitative study.

Author: Helma van Osch Student number: 0431109 Key words: domestic violence, victims, detection, General Practitioner Cooperatives Research internship 07-02-2011 untill 29-04-2011 Supervisors: Prof. dr. A.L.M. Lagro-Janssen Contact: [email protected] Dr. S.H. Lo Fo Wong Contact: [email protected] 1 Bent u op zoek naar hulp, trainingen of wilt u meer informatie over familiaal en huiselijk geweld? Kijk dan op onze website: www.sfgnijmegen.nl of neem contact op per e-mail: [email protected]

Datum: 28-1-2013

Inhoud SAMENVATTING (Nederlands) ...................................................................................................................... 3 Achtergrond: ............................................................................................................................................. 3 Doel: .......................................................................................................................................................... 3 Methode: ................................................................................................................................................... 3 Resultaten: ................................................................................................................................................ 3 Conclusie: .................................................................................................................................................. 3 ABSTRACT ...................................................................................................................................................... 4 Introduction:.............................................................................................................................................. 4 Aim: ........................................................................................................................................................... 4 Methods: ................................................................................................................................................... 4 Results: ...................................................................................................................................................... 4 Conclusion: ................................................................................................................................................ 4 INTRODUCTION ............................................................................................................................................. 6 METHODS ...................................................................................................................................................... 8 Methods .................................................................................................................................................... 8 Study group ............................................................................................................................................... 8 Participants ................................................................................................................................................ 9 Data collection ........................................................................................................................................... 9 Analysis ...................................................................................................................................................... 9 RESULTS ....................................................................................................................................................... 10 Background.............................................................................................................................................. 10 THEMES OBTAINED FROM EXPERTS........................................................................................................ 11 RESULTS OBTAINED FROM GENERAL PRACTITIONERS ........................................................................... 14 DISCUSSION ................................................................................................................................................. 19 Strengths and limitations of this study.................................................................................................... 20 Conclusion ............................................................................................................................................... 20 REFERENCES ................................................................................................................................................ 21 APPENDIX A: ................................................................................................................................................ 22 APPENDIX B: ................................................................................................................................................ 24 APPENDIX C: ................................................................................................................................................ 25

2 Bent u op zoek naar hulp, trainingen of wilt u meer informatie over familiaal en huiselijk geweld? Kijk dan op onze website: www.sfgnijmegen.nl of neem contact op per e-mail: [email protected]

Datum: 28-1-2013

SAMENVATTING (Nederlands) Achtergrond: Familiaal huiselijk geweld is een veelvoorkomend en moeilijk internationaal en nationaal probleem. Het is aannemelijk dat slachtoffers van familiaal huiselijk geweld in Nederland relatief vaak de Huisartsenpost bezoeken. Echter, het is bekend dat de detectie van slachtoffers van geweld laag is. Het gebruik van een systematisch instrument wordt als zinvol beschouwd bij de ondersteuning van de detectie van slachtoffers van geweld. Op dit moment is zo’n instrument in Nederland niet voorhanden.

Doel: Het uiteindelijke doel van deze studie is om de detectie van slachtoffers van familiaal huiselijk geweld te verbeteren, en daarmee de medische zorg voor deze slachtoffers te verbeteren, door het ontwikkelen van een werkbaar signaleringsinstrument voor de situatie van de Huisartsenpost. Voor de ontwikkeling van een dergelijk instrument is het noodzakelijk om de visies van huisartsen op detectie van slachtoffers van familiaal huiselijk geweld op de Huisartsenpost te exploreren. De problemen die zij ervaren moet nader uitgediept worden, met de bedoeling om relevante bevindingen te benutten bij de ontwikkeling van een optimaal werkbaar signaleringsinstrument.

Methode: Kwalitatief onderzoek in de vorm van focusgroepsgesprekken. Eerst werd een focusgroep met zeven deelnemers met expertise op het gebied van de detectie van familiaal huiselijk geweld georganiseerd, om meer inzicht te krijgen in het onderwerp. Daarna zijn vier interactieve discussies gehouden met in totaal 21 huisartsen, om hun visies te exploreren. De opgenomen en uitgetypte discussies werden geanalyseerd door twee onafhankelijke onderzoekers.

Resultaten: Huisartsen herkennen signalen van familiaal huiselijk geweld op de Huisartsenpost slecht, omdat ze de patiënten en hun medische achtergrond en andere omstandigheden niet kennen. De lage alertheid op familiaal huiselijk geweld wordt veroorzaakt door de specifieke omstandigheden op de Huisartsenpost, die de dokter dwingen om zich te focussen op urgente medische problemen, ten gevolgen van hoge werkdruk en tijdsgebrek. Daarnaast is de kennis van de huisartsen over de signalen van familiaal huiselijk geweld gebrekkig. Daarnaast laat deze studie zien dat huisartsen niet weten wat ze moeten doen wanneer ze een verdenking hebben op familiaal huiselijk geweld op de Huisartsenpost. Huisartsen denken zeer verschillend over de taakopvatting. Een heldere taakomschrijving is nodig, die taken omvat die realistisch uitgevoerd kunnen worden op de Huisartsenpost. Tevens moet de verantwoordelijkheid gedefinieerd worden. Huisartsen zijn skeptisch over een signaleringsinstrument, omdat er voor elk topic in de huisartsgeneeskunde protocollen bestaan. Ze benadrukken dat een instrument kort en snel moet zijn, en idealistisch medische problemen en signalen omvat die zich specifiek op de Huisartsenpost voordoen. Een instrument zou opgenomen moeten worden in de automatisering, op een dusdanige manier dat de dokter er niet omheen kan voordat hij een consult kan afsluiten. Van belang is, dat het instrument niet mag uitnodigen tot ‘afvinken’ of tot het vermijden van zelf nadenken. De eerste stap in het verbeteren van detectie van slachtoffers van familiaal huiselijk geweld op de Huisartsenpost is de alertheid in het algemeen te vergroten door training.

Conclusie: De resultaten van deze studie geven een indicatie waarom de detectie van slachtoffers van familiaal huiselijk geweld op de Huisartsenpost zo laag is. Daarnaast worden mogelijke aangrijpingspunten voor verbetering gegeven. De resultaten van deze studie kunnen bijdragen aan verbetering van de detectie van slachtoffers van familiaal huiselijk geweld op de Huisartsenpost, om op die manier de medische zorg voor deze slachtoffers te verbeteren. 3 Bent u op zoek naar hulp, trainingen of wilt u meer informatie over familiaal en huiselijk geweld? Kijk dan op onze website: www.sfgnijmegen.nl of neem contact op per e-mail: [email protected]

Datum: 28-1-2013

ABSTRACT Introduction: Domestic violence is a common and difficult international and national problem. It’s presumable that in the Netherlands, victims of domestic violence are frequent visitors of the General Practitioner Cooperatives. This is a place where general practitioners from the region provide out-ofhours care in large-scale rotations for people with urgent medical problems. However, detection at the GP Cooperatives is poor. It is stated that the use of systematic instruments is useful in detection of victims of domestic violence. However, at the moment there are no reliable instruments.

Aim: The final aim of this study is to improve detection of victims of domestic violence to improve medical care by creating a workable instrument for general practitioners at the GP Cooperatives to detect these victims. In order to realize this aim, it is necessary to explore the opinions of general practitioners about detecting domestic violence at the GP Cooperatives. The problems they experience should be studied more deeply than before with the aim to gain relevant findings which can be used for creating an optimal workable instrument for detecting domestic violence.

Methods: Qualitative focus group study method was used, including 4 interactive discussions between 4-8 general practitioners from their personal point of view about specific topics related to the detection of victims of violence at the GP Cooperatives. Firstly a discussion about domestic violence was organized with an expert focus group to discuss their opinions about problems in detecting domestic violence at the GP Cooperatives and in this way, explore the subject more deeply. Seven participants with special expertise in domestic violence were included. In the 4 focus groups with general practitioners a total number of 21 general practitioners was participating. Analysis included the typewritten version of the audiotaped discussions by two independent researchers.

Results: General practitioners do poorly recognize signs of violence at the GP Cooperatives, because they don’t know the patients visiting them, nor their medical history or family. The low awareness for violence is also caused by specific circumstances, which force the doctor to focus on urgent medical problems, due to considerable overloading workload, because of lack of time. Furthermore, general practitioners lack sufficient knowledge about (signs of) violence. Also, this study shows that general practitioners don’t know what to do when they suspect (a sign of) violence at the GP Cooperatives. They experience important differences in task conception. There is need for a clear task circumscription for the general Practitioner at the GP Cooperatives, which should include tasks that can be realistically effected during work at the GP Cooperatives, with a precisely definition of the responsibilities. An instrument aiming to support detection and increase awareness meets many doubts in general practitioners. In fact, they are skeptical about any instrument. They emphasize that any instrument should be practical, short and quick. Ideally, an instrument should include medical problems and signs which specifically present at the GP Cooperatives. It should be included in the medical computer program, in such a way the doctor can’t avoid it before finishing any visit. Most importantly the instrument should not invite for just ‘ticking’ or avoiding general practitioners from thinking. According to the general practitioners, the first step in improving detection of victims of violence at the GP Cooperatives is to increase the awareness for the problem among general practitioners by training.

Conclusion: The results of this study give us an indication why detection of victims of violence at the GP Cooperatives is poor. Also, these results give us possible targets for improvement. In this way, the 4 Bent u op zoek naar hulp, trainingen of wilt u meer informatie over familiaal en huiselijk geweld? Kijk dan op onze website: www.sfgnijmegen.nl of neem contact op per e-mail: [email protected]

Datum: 28-1-2013

results of our study, can contribute to improved detection of victims of domestic violence by general practitioners at the GP Cooperatives.


Datum: 28-1-2013

INTRODUCTION Domestic violence is a worldwide common problem, and health services focusing on it is an international priority1. Also in the Netherlands domestic violence is a serious and extensive social- and health problem and the most common form of violence in our society2,3,4. Recently the Dutch governmental policy is more focused on domestic violence5. The term ‘domestic violence’ covers a broad range of family violence, but mostly affects women and children2,5. Mostly females are victim of physical abuse that is committed by an (ex-) partner4-8. Victims of partner abuse have to deal with serious health consequences like obvious and visible signs of battering and less-obvious chronic somatic or mental complaints1,4-8. Child abuse encompasses any acts of commission or omission by a parent or other caregiver that results in (potential) harm to a child up to 18 years of age9. The most reported health consequences of child abuse, besides visible physical signs, are those of behavioral problems9,10. Because of the major impact of domestic violence on healthiness, it is an important task of health care professionals to detect domestic violence1,4. Of all professionals, the general practitioner is mostly the first one where victims seeks for help11. This study focuses on detecting domestic violence at the General Practitioner Cooperatives (GP Cooperatives). In the Netherlands, people with urgent medical problems in the evening, night and at the weekend visit the GP Cooperatives for out-of-hours care, where general practitioners from the region provide care in large-scale rotations. Experts presume that victims of domestic violence frequently visit the GP Cooperatives12, because of the anonymous conditions it provides: patients avoid their own general practitioner (‘shopping’), consulting a doctor who’s not familiar with their backgrounds, nor medical history, which are ‘favorable’ conditions, because generally most victims want to keep domestic violence in private. Besides, previous literature describes that victims of domestic violence are frequent users of medical services in general6,13,14, including Hospital Emergency Departments, where possible one in three women presents with domestic violence4,15,16. Considering this, one can assume that victims of domestic violence also visit the GP Cooperatives more frequently than people without a history of violence. Unfortunately it is known that general practitioners seldom recognize partner abuse 7. Detection of child abuse at the GP Cooperatives is recently examined and is also considered poor16. Better detection of victims of domestic violence at the GP Cooperatives would provide an opportunity for better care for these victims4,12. What could be reasons for the poor detection of victims of domestic violence specifically at the GP Cooperatives, while literature and experts expect them to be frequent visitors? An obvious important cause is that general practitioners seldom recognize domestic violence at all, which is in the first place because both doctors and patients seldom disclose abuse spontaneously7. Both experience a number of barriers to discuss abuse in the medical visit. Besides, one can imagine that unfamiliarity with the patient and her history could also be partly responsible for the poor detection by general practitioners at GP Cooperatives. It is stated that the use of systematic instruments is useful in detection of victims of domestic violence 4. However, at the moment there are no reliable or validated instruments. The sensitivity of most screening instruments used in the past turned out to be moderate. No trials on the effectiveness of screening in healthcare settings for reducing harm to victims of abuse have been published17. In the Netherlands the SPUTOVAMO protocol (see appendix A) is a widely used detection instrument for physical child abuse at the Emergency Department in hospitals18. This protocol is sometimes also used by general practitioners at GP Cooperatives. Nevertheless the Ministry of Health concluded in 2010 that the detection of victims 6 Bent u op zoek naar hulp, trainingen of wilt u meer informatie over familiaal en huiselijk geweld? Kijk dan op onze website: www.sfgnijmegen.nl of neem contact op per e-mail: [email protected]

Datum: 28-1-2013

of child abuse at the General practitioner cooperatives is very poor12. Besides, it detects no other forms of abuse than physical abuse, and only in children. The final aim of this study is to improve detection of victims of abuse to improve medical care. By creating a workable instrument for general practitioners at the GP Cooperatives to detect victims of domestic violence. In order to realize this aim, it is necessary to explore the opinions of general practitioners about detecting domestic violence at the GP Cooperatives. The problems they experience should be studied more deeply than before with the aim to gain relevant findings which can be used for creating an optimal workable instrument for detecting domestic violence. This study will focus on exploring the opinions of general practitioners. This will be done by focus group study methods, including text analysis of the typewritten audiotaped group discussions. We formulated the research questions listed in table 1. Table 1: Research questions.

Primary question: What problems do general practitioners experience in detecting domestic violence at the General Practitioner Cooperatives? Subquestions: 1. Do general practitioners have sufficient knowledge on specific signs of domestic violence? 2. What are obstacles in detecting abuse at the GP Cooperatives? 3. What is the readiness of general practitioners to detect domestic violence at the GP Cooperatives? 4. What could be facilitating factors in detecting abuse at the GP Cooperatives?


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METHODS Methods Because we wished to get more deeply insight into experiences and views of general practitioners about detecting domestic violence at the GP Cooperatives and this has not been studied before, we used a qualitative research method. By exploring the field this study aims to explore problems that family practitioners experience in detecting victims of domestic violence at the GP Cooperatives. In order to realize this, focus group study method was used: an interactive discussion between 4-8 general practitioners from their personal point of view about specific topics related to the detection of victims of violence at the GP Cooperatives. By using the focus group study method insight was gathered about experiences and functioning of the groups. Involved participants were stimulated to compare their ideas and experiences with others. This process of ‘sharing and comparing’ resulted in a wide view on every topic discussed. The focus groups took 1-1,5hour each and were leaded by an experienced moderator and observed by an observator. The discussions held within the focus groups were recorded. Afterwards, the discussions were fully typewritten. Figure 1: study design

Focus group study N = 5 Number of participants: 6 experts, 21 general practitioners

Arnhem

6 experts

6 GP's Arnhem

Nijmegen

7 GP's Arnhem

3 GP's Nijmegen

5 GP's Nijmegen

Study group Expert group Firstly a discussion about domestic violence was organized with an expert focus group to discuss their opinions about problems in detecting domestic violence at the GP Cooperatives and in this way, explore the subject more deeply. Seven participants with special expertise in domestic violence were included: 4 of them were general practitioners. One was an experienced employee of a specialized aid agency (Stichting HERA) and one was a doctor at a child protection agency (AMK). Thereafter the same topics and the findings from the expert group were discussed in 4 following focus groups with general practitioners. General practitioner group From in and around Arnhem and Nijmegen, ‘ordinary’ general practitioners were included in four groups. The population was restricted to Arnhem and Nijmegen because the Department of Family Medicine (UMC St Radboud) has contacts in both GP Cooperatives who are willingly to cooperate in this study since there is notable local interest for the improvement of detection and management of partner abuse. 8 Bent u op zoek naar hulp, trainingen of wilt u meer informatie over familiaal en huiselijk geweld? Kijk dan op onze website: www.sfgnijmegen.nl of neem contact op per e-mail: [email protected]

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Participants To realize a wide variety general practitioners were selected on age, gender, cultural background, years of practice, form of practice (single/group), place of practice (city/small village), factors that are expected to be of influence on their experience about the subject. From Arnhem, 14 out of 20 approached doctors agreed to participate. One dropped out for the focus group meeting because of illness. In Nijmegen, 34 general practitioners were invited, of whom 8 agreed to participate. Time-investment and not being available at the pre-arranged meetings were the main reasons for non-response.

Data collection A short questionnaire provided demographic data. A moderator experienced in leading focus group processes conducted the four focus groups. The focus group discussion interview guide was based on literature and expert opinion. Group discussions were recorded on audiotape. Table 2: Interview guide

1. Did you ever suspect domestic violence at the GP Cooperatives? Based on what signs? How did you act? 2. What are obstacles in identifying victims of domestic violence at the GP Cooperatives? 3. What are facilitating factors in detecting victims of domestic violence at the GP Cooperatives? 4. What is your opinion about the readiness of general practitioners to detect/discuss domestic violence at the GP Cooperatives? 5. Can a screenings instrument contribute to an adequate identification of victims of domestic violence at the GP Cooperatives?

Analysis Analysis started directly after a focus group meeting: the moderator and observator shared their impressions about the group, including their observations, their notes and descriptions of non-verbal interactions. Further analysis included the typewritten version of the audiotaped discussions and the notes about non-verbal behavior. All comments were sorted by key question. In the first phase (‘open encoding’), by reading and rereading19, keywords were attached to the text segments. In this way, the central themes were explored. In the phase of ‘directed encoding’, the applicability of the keywords were assessed on new material. In this phase, the keywords resulting from analysis of the expert focus group were assessed in the general practitioner focus groups and findings from general practitioner focus groups were tested in following general practitioner focus groups. By comparative analysis of segments in which a central topic has been discussed, the keywords of that topic were abstracted for similarity, differences and variation in underlying dimensions. Two researchers independently searched for patterns that emerged from each question and subsequently they defined the most important themes together. In case of disagreement both researchers succeeded in reaching consensus after discussion.


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RESULTS Background The participants were from all ages and years of experience as general practitioner (table 3). Most are working with two or more collegues, which is in accordance with the usual Dutch practice type. Table 3: Demographics of focus group participants (family doctors)

Age: <40yrs 40-50yrs > 50yrs Practice type: Solo Group (≥2) Health centre District type: Wealthy Mixed Deprived Full-/part-time: FT ≥4days PT<4days Yrs of practic†: <10yrs 10-20yrs >20yrs

Male n = 9 (%)

Female n = 12 (%)

Total n = 21

2 2 5

3 4 4

5 6 9

3 5 1

0 8 2

3 12 3

6 2 1

6 4 -

12 6 1

7 2

4 7

11 9

3 2 4

3 4 4

6 6 8


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THEMES OBTAINED FROM EXPERTS Obstacles Poor recognition Experts thought the main obstacle in detection is poor recognition, because the general practitioners working at the GP Cooperatives don’t know any background the patients visiting them, nor context nor medical history. Besides, general practitioners lack knowledge on signs of domestic violence, because the signs are generally different from the cases in their very own practice. And the experts suspected that when general practitioners do recognize victims of violence, it is only when patients present with obvious physical signs. ‘Generally, doctors don’t think about violence as a possible underlying cause for the complaint the patient at the GP Cooperatives presents. For example, a general practitioner does see that a patient is very anxious or depressed, but does not come to the idea that the complaints can be based on violence.’ (F, 60yrs) Task conception A second problem is that general practitioners don’t know what to do when they come across a possible sign of violence. Management of (suspected) domestic violence is a complex matter in any case, but more complex when it is suspected at the GP Cooperatives in a patient the general practitioner does not know and whom the general practitioner probably will be seeing only once. The core of the problem is, experts think, that general practitioners at the GP Cooperatives don’t know what in that context their specific task and responsibility is. ‘What should I do? is the first response of any doctor who suspects violence’. (F, 64yrs) ‘In my own practice, I know exactly my responsibility for detecting violence and discussing it with my patient. And I stand for everything that my acts may result in, I stand for the consequences of my handling. Those consequences aren’t there in a one-off act of me at a General practitioner cooperatives.’ (F, 62yrs) Other obstacles Time constraints played an important role: general practitioners don’t know how to handle this complex matter properly in a visit of ten minutes. Known pitfalls like a judging attitude based on personal views and cognitions on violence are also hindrances in discussing violence. Besides, general practitioners feel uncomfortable when they have to discuss difficult subjects. ‘The fear to make false accusations withholds the general practitioners from acting.’ (F, 52yrs) ‘They should be realizing that they (GPs) don’t have to find out ‘the truth’ about this complex matters, nor that they should blame something or someone.’ (F, 45yrs) ‘Learning about their own personal views on violence can be very helpful.’ (F, 54yrs)


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Facilitating factors and solutions Increase awareness, willingness to identify and training/education Experts thought that firstly general practitioners should be convinced about the importance of violence for health issues in order to increase the willingness among general practitioners to identify domestic violence. ‘We (referring to participants of expert focus group discussion) aren’t the ones to be convinced on this issue.. The whole friction point is: how can this topic be normalized among doctors?’ (F, 64yrs) Therefore general practitioners should be trained in detecting domestic violence in the specific situation of the GP Cooperatives. Specific complaints and signs, attitudes, personal views and cognitions and communication should be included in this training. Tasks The specific task of the general practitioner at the GP Cooperatives should be clearly defined in relation to the patient’s own general practitioner. Experts agree that the task of the general practitioner at the GP Cooperatives should be realistically manageable. It should possible be restricted to evident cases. ‘Difficult are patients visiting the GP Cooperatives frequently with chronic unspecific complaints like abdominal pain. Those cases shouldn’t be included, but should be managed by the patient’s own doctor’. (F, 60yrs) Instrument for identification of victims of domestic violence at the GP Cooperatives Supportive function Firstly, any instrument should facilitate and support detection. It should increase the awareness of the problem and should provide some help in detection and management of domestic violence at the specific situation of the GP Cooperatives. Of great matter is, that it should not stop the doctor from thinking and communicating him- or herself. In the context of the supporting and helping function of the instrument is also important that it should not be used for defensive goals: ‘Doctors should not be just ticking checklists out of fear for legal consequences. That doesn’t help anyone.’ (F, 62yrs) Workability/Applicability Secondly, any instrument should be operable. Therefore it should not be too extended. It should be workable implemented in the system, ideally in the medical computer program. Also the triagists need to be included in any system. To make any instrument operable, doctors need training on it. Sputovamo protocol More than ones experts mentioned that today the Sputovamo protocol for detection of child abuse in emergency departments of hospitals and at GP Cooperatives is the most used instrument. Experts thought it is not appropriate for the detection of violence in the GP Cooperatives, because it only includes children. Thereby, experts assessed the Sputovamo protocol is not appropriate, because it lacks room for the specific expertise of general practitioners. It ‘just’ includes detection of violence by 12 Bent u op zoek naar hulp, trainingen of wilt u meer informatie over familiaal en huiselijk geweld? Kijk dan op onze website: www.sfgnijmegen.nl of neem contact op per e-mail: [email protected]

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analyzing specific features of physical injury. It barely includes behavior and other important features in detecting violence. Content Concretely, the experts suggested the items mentioned in table 4 should be included in the development of a detection instrument for domestic violence applicable at the GP Cooperatives. The detection instrument should include also a protocol with ‘how to act after detection of (a sign of) violence’. Table 4: Items composed by experts, to include in a detection instrument for domestic violence at the GP Cooperatives.

-

-

A feeling from the doctor that says ‘something is wrong’ Suspicious medical history, for example visit frequency Disorders which are importantly related to violence in previous research, like o Physical trauma’s  < 5 yrs old: always full physical examination from head to toes  > 5 yrs old without any delay, and with an appropriate explanation, no suspected medical history: not suspected o Pregnancy problems, especially vaginal bleedings o Excessive crying babies, infants < 1 yr with feeding problems o Anxiety disorders, hyperventilation, panic disorders Behavioral features: o Inadequate or inconsistent explanation for the trauma o Inadequate help seeking behavior, delay in presentation o Strange attitude, for example neglect o Problems in interaction between patient and any accompanying person, like partner or child


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RESULTS OBTAINED FROM GENERAL PRACTITIONERS Obstacles Poor recognition The vast majority of the general practitioners has a blind spot for domestic violence. When they were asked if they ever suspect domestic violence at the GP Cooperatives, they often answered: ‘No, I didn’t, but based on statistics, I should have been suspecting it more than ones. So it must have passed me.’ (M, 52yrs) In every group there was at most one participant who had ever noticed a suspicion of domestic violence at the GP Cooperatives in the written message to the patient’s own general practitioner. Only one of them once discussed a suspicion with the patient. Generally this failure to recognize domestic violence was explained by specific circumstances at the GP Cooperatives of not knowing the patient, nor context or history. When they were asked what signs of domestic violence presented at the GP Cooperatives they knew, in all the groups ‘the feeling that something is wrong’ was the most prominent sign. (Read appendix C for a case of a GP who suspects violence during work at the GP Cooperatives.) Other signs general practitioners mentioned were inadequate explanations, frequent visiting of the GP Cooperatives with strange little traumas, and an unexpected accompanying person. All groups mainly expressed their suspicions in evident cases of physical injury in combination with inadequate stories about how the injury became about, especially in children, thereby confirming the thoughts of the expert group. But even in case of what experts consider the most obvious signs of violence at the GP Cooperatives, some of the participants expressed: ‘You don’t think of abuse in every case of fracturing!’ (M, 54yrs) All general practitioners recognized that the awareness for detecting violence when they are working at the GP Cooperatives is very low. In this context time pressure is the most mentioned obstacle in detecting domestic violence. Some groups more deeply discussed the reason for the poor alertness for detecting violence. In two out of four groups, participants stated that they are acting with a different, more strictly medical focus when they are working at the GP Cooperatives compared to their own practice, mainly because of time pressure and crowded waiting rooms: ‘When I’m working at the General Practitioners Cooperative, I am another kind of doctor: I have to work in a rapid tempo, so I’m focusing on the acute health complaints – is it broken or not?, I don’t focus enough on the environmental factors. Besides, there is hardly time to overlook your work.’ (F, 46yrs) However in all groups, all participants confirmed the importance of detection and action by the general practitioners at the GP Cooperatives, ‘General practitioners do also have blind spots and pitfalls, the opinion of an independent colleague can be very helpful by bringing new insights.’ (M, 34yrs) Task conception In every group there was discussion about if, and in what way, and in which extend, general practitioners at the GP Cooperatives should discuss any presumption of (a sign of) domestic violence with the patient and with the patient´s own general practitioner. 14 Bent u op zoek naar hulp, trainingen of wilt u meer informatie over familiaal en huiselijk geweld? Kijk dan op onze website: www.sfgnijmegen.nl of neem contact op per e-mail: [email protected]

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Some participants stated that the general practitioner at the GP Cooperatives shouldn’t discuss any suspicion based on not obvious signs with the patient during the consultation: ‘A general practitioner who does not know the patient visiting him, and who’s working under time pressure, should not discuss ´just´ a feeling that something is wrong, which is mostly the only sign.’ (F, 44yrs) These participants stated that general practitioners who don´t have a very strong suspicion for domestic violence, shouldn´t risk a false accusation, which in case of domestic violence is a very heavy accusation, with an impact and consequences the doctor cannot oversee adequately because the patient is unknown. Another reason is the fact that the doctor has got only a single consult of ten minutes, with luck possibly twenty minutes, which is way too short to detect and handle this complex matter adequately in a patient they don’t know. Participants who support this idea, suggest that a general practitioner reports his feeling that something is wrong to the patients own general practitioner, who is more competent to estimate if domestic violence could be the case. Nevertheless, as much participants expressed they do think general practitioners at the GP Cooperatives should discuss their suspicion with the patient, despite the uneasy circumstances to discuss this complex matter. ‘One should strike the iron while it’s hot.’ (F, 41yrs) ‘The general practitioner who is not familiar and less involved with the patient, is able to ask this unknown patient about violence unprejudiced.’ (M, 58yrs) So these participants think that because of loyalty the fear to make false accusations is more prominent when the patient’s own general practitioner brings the subject forward in discussion compared to the ‘temporary doctor’ at the GP Cooperatives. The own general practitioner is taking more risks about damaging the patients trust in him. Besides, these participants state that, by discussing it, the doctor at the GP Cooperatives opens a door for the patient’s own general practitioner to discuss it more easily. Facilitating factors and solutions Increase awareness, willingness to identify and training/education In all groups participants themselves brought in that all general practitioners should be competent to detect domestic violence at the GP Cooperatives. Therefore it is most essential that general practitioners should become more focused on the detection of victims of- and signs of violence when they are working at the GP Cooperatives. In some groups the concept of normalizing the subject was more deeply discussed. All participants stated that doctors should include detecting of violence in their systematic thinking. But also, the concept of normalizing was discussed as follows: ‘Doctors should get rid of their embarrassment to discuss this matter’. (F, 40yrs) Increasing awareness could probably be achieved by training. Training should include recognition of signs, but also the communicative skills to discuss it: ‘Of course we have all learned how to discuss things, but child abuse in a patient you don’t know is in all probability more difficult than a sexual transmitted disease. Training would help increase the certainty with which you dare to discuss it.’ (M, 35yrs) 15 Bent u op zoek naar hulp, trainingen of wilt u meer informatie over familiaal en huiselijk geweld? Kijk dan op onze website: www.sfgnijmegen.nl of neem contact op per e-mail: [email protected]

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However, in the context of training, some participants specifically underline the recalcitrance character of the subject. Detection of violence at the GP Cooperatives remains very tough. Beside constructive training, different manners of how to increase the awareness for detection of violence are mentioned: a guiding policy measure or –rule, or creating attention for the subject by introducing ‘the month of violence’ with folders and information at the GP Cooperatives and posters in the waiting room to invite patients to discuss violence. Task conception There was no uniformity among general practitioners within the groups when it comes to task conception about detecting violence at the GP Cooperatives. There were different opinions about facilitating factors: some thought an unknown doctor who’s bringing a feeling that something is wrong, or another possible sign of violence into discussion with the patient is facilitating for further detection and handling of violence by the patient’s own doctor: ‘Discussing it directly with a patient opens a door for the patient for help AND opens a door for the own general practitioner to continue detection process.’ (F, 34yrs) Others preferred that the doctor at the GP Cooperatives only discusses any suspicion with the patient’s own general practitioner. However, it was considered to be doubtful into which extent this can be done without informing the patient. Communication Some groups discussed the communication between the general practitioner at the GP Cooperatives and the patient’s own general practitioner. Most participants stated that idealistically, there would be contact by telephone as soon as possible after suspecting (a sign of) violence in a patient. However, this seemed not to be realistically feasible, so participants prefers a clear notification in the standard electronic written message for the patient’s own general practitioner. Secondly, some participants emphasized the importance of the professional’s attitude, including personal views on the subject, and communication skills in the approach of the complex problem of domestic violence: ‘No judging attitude! But a neutral, inviting attitude.’ (F, 28yrs) ‘Real, sincere contact and trust are essential in discussing this matter.’ (F, 46yrs) Detection instrument Supportive function Most participants recognized that a (hypothetic) detection instrument should aim to- and could increase the awareness for violence by implementing it in the doctor’s own working system. In all groups, participants consider the function of any (hypothetic) detection instrument to be a mnemonic one. And by using it, it should make the doctor more alert over time. However, in every group, participants are skeptic about any instrument. Most general practitioners seem to be not great fans of protocols:


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‘How can this properly be implemented in the system? We must admit that we’re not very good in working with protocols. Like there are so many wonderful tools, but the moment you need them, you don’t think about them or you can’t find them.’ (F, 34yrs) ‘The danger is, that there is a protocol for every topic in family medicine. How can it be kept actual?’ (M, 35yrs) All groups brought in that any instrument should not stop the doctor from communicating. The doctor should have a neutral, inviting, nonjudging attitude. Therefore, by some participants it was suggested to ask every patient for violence, so it becomes a really neutral question, and by asking it a lot, it becomes more easy for the doctor to discuss the subject. Finally, most participants do not prefer ticking checklists. Workability Following the skeptic attitude towards a detection protocol, all participants principally expressed their ideas about the practical side of any hypothetic instrument: it should be workable, and therefore in the first place it should be clear and not be too extended. For example, one group suggested a maximum of three (multiple choice) questions, of which the outcome determined what to do based on a protocol. Another group suggested that there should only be one basic question to alert the doctor. Furthermore, the instrument should not be ‘just another protocol,’. And it should be realistically manageable in the restricted circumstances at the GP Cooperatives, so it should be easy to find and working easily and quickly: ‘It must absolutely cost the minimum of effort.’ (M, 54yrs) Besides, one should not have a chance to get around the instrument. Therefore, all groups brought in themselves that most ideal would be to include the instrument in the medical computer program, so the computer forces the doctor to do something with it. Participants suggested that in some cases, the computer could remind the doctor of using the instrument, for example in frequent visitors, or extended medical history, or in all announced cases covered by ICPC-code ‘trauma’. Some groups discussed the idea that in those cases the computer demands certain items before the doctor is able to finish the consult digitally. A frequently discussed item was getting feedback. Many participants support the learning experience from feedback. For example, some suggested to evaluate all or some consults with a independent colleague, in an attempt to specify what exactly caused their feeling that ‘something is wrong’. Also many support feedback to triagists who increase the doctor’s awareness by mentioning signs they have noticed. Content Generally, all participants agreed that evident tangible cases should be included in an instrument. So, in every physical injury violence should at least be considered. Further, they strongly underlined the broad variety of nonspecific complaints victims of violence can present and in this way it is difficult to work directed by specific complaints. However, ideally they would like to include concrete situations which occur specifically at the General Practitioner Cooperative. One group discussed that mainly ‘best predictors’ should be included to achieve optimal efficiency and feasibility. Chronic unspecific complaints, like abdominal pain, are not to be included.


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Table 5: Items suggested by general practitioners to include in a detection instrument for domestic violence at the GP Cooperatives.

-

-

-

Evident cases. In every physical injury violence should at least be considered o Especially trauma’s with an inappropriate explanation Concrete disorders, which specifically present at the GP Cooperatives,which are importantly related to violence in previous research (‘best predictors’). Suggestions: Adults: o Anxiety disorders and depression o Substance abuse o Requests for hypnotics o Personality disorders In children: o Inadequate psychological development o Anxious children or depressed or hyperactive children The feeling that something is wrong Frequent visitors of GP Cooperatives Behavioral features characterized by ‘unusual, nonregular situations’ like: o Inadequate explanation for the complaints o Unexpected accompanying person o Inconsistent interaction between patient and any accompanying person, like partner or child o Inconsistency in affect: suppression, dependence, neglect Registrations of notable findings (rubbish, interactions between peoples, etc.) during a homevisit at the GP Cooperatives


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DISCUSSION General practitioners do poorly recognize signs of violence at the GP Cooperatives, because they don’t know the patients visiting them, nor their medical history or family. The low awareness for violence is also caused by specific circumstances, which force the doctor to focus on urgent medical problems, due to considerable overloading workload, because of lack of time. Furthermore, general practitioners lack sufficient knowledge about (signs of) violence. Also, this study shows that general practitioners don’t know what to do when they suspect (a sign of) violence at the GP Cooperatives. In their own practice, general practitioners feel very responsible for the consequences of their handling. This is different for the situation of the GP Cooperatives. That’s why general practitioners don’t know exactly what to do when they suspect violence during work there, and there are important differences in task conception. There is need for a clear task circumscription for the general Practitioner at the GP Cooperatives. Tasks that can be realistically effected during work at the GP Cooperatives, with a precisely definition of the responsibilities. An instrument aiming to support detection and increase awareness meets many doubts in general practitioners. in fact, they are skeptical about any instrument because they experience the total number of protocols and instruments for general medicine to be excessive and in that way, not functional. They emphasize that any instrument should be practical, short and quick. Ideally, an instrument should include medical problems and signs which specifically present at the GP Cooperatives. It should be included in the medical computer program, in such a way the doctor can’t avoid it before finishing any visit. Most importantly the instrument should not invite for just ‘ticking’ or avoiding general practitioners from thinking. According to the general practitioners, the first step in improving detection of victims of violence at the GP Cooperatives is to increase the awareness for the problem among general practitioners. General practitioners should be more focused on the problem that the incidence of violence among visitors of the GP Cooperatives is high. In time they should include violence in their systematic thinking. This can be effectuated by training in signs of violence specifically presenting at the GP Cooperatives and in how to manage after disclosure violence. Our study provides new views on the detection of victims of domestic violence, namely under the specific circumstances of the GP Cooperatives. These specific circumstances have not been studied before. The best parallel studies are those including detection of violence at Hospital Emergency Departments. The poor detection of violence by the general practitioners in our groups confirms previously studies. The incidence rates of child abuse at Hospital Emergency Departments have been reported to range from 2% to as high as 10%21, however, the detection rate of child abuse at EDs in the Netherlands (assessed for 2001-2004) was only 0.1%21. Also many battered women who present to the Hospital Emergency Department are misdiagnosed with non-violence etiologies16. According to literature misdiagnosing is partly caused by failure to actively screen for violence when it was appropriate to do so16,21. However, literature does not provide more profound research into the reasons and origin of poor detection. This study provides more deeply insight in why professionals experience detection of violence as problematic, which forms an important base for improvement of detection of victims of violence, in our specific case under the circumstances of the GP Cooperatives. Furthermore, their thoughts about what could be helpful for them to improve detection of violence, including aspects of any detection instrument, could help us develop an efficient, useful and workable detection instrument for victims of violence at the GP Cooperatives.


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Strengths and limitations of this study A strong methodological point of this study, is that within the process of information gathering, theoretical saturation took place. According to literature, in this type of research with homogeneous groups, in general, theoretical saturation will be reached after two to four groups7,20. As we included four groups, and as after three groups actually no new themes were emerged, we approximated saturation. Generally, the reliability of qualitative research methods is limited as a direct result of the methodology. However, increasing reliability was aimed by audiotaping and fully typewriting the group discussion, and by continuously peer debriefing by a fellow researcher who was working on another project but with the same theme. Also, results were analyzed by two independent researchers. The main limitation of this study is that most general practitioners who agreed to participate have more affinity with domestic violence than usual. So we probably miss the opinion of general practitioners who could consider domestic violence not to be a medical issue and therefore think differently about task conception of the general practitioner at the GP Cooperatives. The results of this study give us an indication why detection of victims of violence at the GP Cooperatives is poor. Also, these results give us possible targets for improvement. In this way, the results of our study, can contribute to improved detection of victims of domestic violence by general practitioners at the GP Cooperatives.

Conclusion We found that the very low awareness among general practitioners for detecting violence at the GP Cooperatives is due to the specific working circumstances at the GP Cooperatives which force the doctor to focus on urgent medical problems, to a lack of knowledge and to unclear task conceptions. Training in detection and management, a clear task circumscription and maybe a workable detection instrument, adjusted to the specific circumstances of the GP Cooperatives, are considered to be possible facilitating factors for increasing awareness and improving detection of victims of violence by general practitioners at the GP Cooperatives. in this context, our study yields concrete suggestions from general practitioners themselves.


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Krug EG. World report on violence and health. Geneva: World Health Organization, 2002. Ferwerda, H. Met de deur in huis. Omvang, aard, achtergrondkenmerken en aanpak van huiselijk geweld in 2006 op basis van landelijke politiecijfers. Politierapport 2007. Van der Veen HCJ, Bogaerts S. Het landelijke onderzoek huiselijk geweld 2010. Justitiële verkenningen, Ministerie van Justitie 2010. CBO. Richtlijn Familiaal Huiselijk Geweld bij kinderen en volwassenen. CBO 2009. Inspectie voor de Gezondheidszorg. Basisset publieke gezondheidszorg: indicatoren. Ministerie van Volksgezondheid, Welzijn en Sport 2010. Garcia-Moreno C, Jansen HAFM, Ellsberg M, Heise. Prevalence of intimate partner violence: findings from the WHO Multi-country study on women’s health and domestic violence. Lancet 2006; 368:1260-69. Lo Fo Wong S. The doctor and the women “who fell down the stairs” – General practitioner’s role in recognizing and responding to intimate partner abuse. Thesis 2006. Campbell JC. Health consequences of intimate partner violence. Lancet 2002; 359: 1331-36. Butchart A, Kahane T, Phinney Harvey A, Mian M, Furniss T. Preventing child maltreatment: a guide to taking action and generating evidence. Geneva: WHO and International Society for the prevention of Child Abuse and Neglect, 2006. Gilbert R, Widom CS, Browne K, Fergussen D, Webb E, Janson S. Burden and consequences of child maltreatment in high-income countries. Lancet 2009;373:68-81. Ministerie van Justitie. Slachtofferschap van huiselijk geweld. Aard, omvang, omstandigheden en hulpzoekgedrag. Wetenschappelijk Onderzoek- en Documentatiecentrum, Ministerie van Veiligheid en Justitie 2010. Inspectie voor de Gezondheidszorg. Huisartsen onvoldoende alert op kindermishandeling. Inventariserend onderzoek naar de kwaliteit van de signalering van kindermishandeling op huisartsenposten. Ministerie van Volksgezondheid, Welzijn en Sport 2010. Victoria SG. The health costs of violence. Measuring the burden of disease caused by intimate partner violence. A summary of findings. Carlton South, Victoria, Australia: Dept. Human Services; Victorian Health Promotion Foundation, 2004:44. Ulrich YC, Cain KC, Sugg NK, Rivara FP, Rubanowice DM, Thompson RS. Medical care utilization patterns in women with diagnosed domestic violence. Am J Prev Med 2003;24(1):9-15 Dearwater SR. Prevalence of intimate partner abuse in women treated at community hospital emergency departments. JAMA 1998-vol 280, No 5. Wu V, Huff H, Bhandari M. Pattern of physical injury associated with intimate partner violence in women presenting to the Emergency Department: a systematic review and meta-analysis. Trauma Violence Abuse 2010;11:71. Ramsay J. Should health professionals screen women for domestic violence? Systematic review. British Medical Journal, 2002;325:314. KNMG. Artsen en kindermishandeling. Meldcode en stappenplan. KNMG 2008. Lucassen P, Olde-Hartman T. Kwalitatief onderzoek: praktische methoden voor de praktijk. 2007. (Strauss A and Corbin J. Basics of qualitative research; Techniques and procedures for developing grounded theory. 1998, London Sage Publications.) Louwers E. Screening for child abuse at emergency departments: a systematic review. Archives of Disease in Childhood 2010;95(3):214-8.


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APPENDIX A: The Sputovamo protocol


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APPENDIX B: Invitation for the study by letter Huisartsgeneeskunde Vrouwenstudies Medische Wetenschappen Prof. Dr. Toine Lagro-Janssen UMC St Radboud, route 117 Geert Grooteplein 21 6525 EZ Nijmegen Huispost 117 Postbus 9101 6500 HB Nijmegen Tel: (024) 361 91 06/361 31 10

24 februari 2011 Onderwerp: Detectie van familiaal huiselijk geweld op de Huisartsenpost Geachte collega, Graag willen wij u vragen om mee te werken aan een onderzoek over ‘Detectie van familiaal huiselijk geweld op de Huisartsenpost’ van de afdeling Vrouwenstudies Medische Wetenschappen van het UMC ST Radboud te Nijmegen. Dit onderzoek zal de afsluitende stage vormen van de studie Geneeskunde van Helma van Osch. Achtergrond Familiaal huiselijk geweld is de meest omvangrijke geweldsvorm in Nederland. Slachtoffers zijn meestal vrouwen en kinderen in heteroseksuele relaties. Wanneer zij hulp zoeken voor klachten die het gevolg zijn van mishandeling, vormt de huisartsenpost vanwege de hoge anonimiteit een veilig toevluchtsoord. Dokters kennen de patiënten meestal niet, er is relatief weinig bekend over de medische voorgeschiedenis en niets over bijvoorbeeld gezinsrelaties. Hierdoor wordt familiaal huiselijk geweld in veel te weinig gevallen onderkend. Om deze reden bestaat er in Nederland een groeiende behoefte aan een signaleringsinstrument voor familiaal en huiselijk geweld, dat gebruikt kan worden op de huisartsposten. Voordat dit instrument echter ontwikkeld kan worden, is gedegen onderzoek nodig naar knelpunten die bij de ontwikkeling naar boven zullen komen, en naar welke aspecten in het instrument verwerkt zullen moeten worden.. Methode Helma zal door middel van focusgroeponderzoek de ervaringen van huisartsen met betrekking tot knelpunten bij het signaleren van familiaal huiselijk geweld op de huisartsenpost exploreren. Op deze manier wordt getracht inzicht te krijgen in de mening van de huisartsen, met als doel deze inzichten mee te nemen bij de verdere ontwikkeling van een signaleringsinstrument voor de detectie van familiaal huiselijk geweld. Uw mening is onmisbaar bij het ontwikkelen van een werkbaar signaleringsinstrument dat toepasbaar is in de setting van de huisartsenpost. Een tweede studente zal de informatie die we denken nodig te hebben bij stakeholders van hulporganisaties voor slachtoffers van familiaal huiselijk geweld onderzoeken. Met deze twee kwalitatieve onderzoeken hopen we over drie maanden op basis van de resultaten aanzet te kunnen geven tot de daadwerkelijke ontwikkeling van een dergelijk signaleringsinstrument. Wij willen u hierbij dus uitnodigen voor een focusgroep over dit onderwerp, die ongeveer 1,5 uur in beslag zal nemen. De focusgroep bestaat uit 6-8 huisartsen, die onder begeleiding zullen discussiëren over het onderwerp. Het gesprek zal op audiotape worden opgenomen, er zal vertrouwelijk met de informatie worden omgegaan. Indien u er interesse in heeft zullen de onderzoeksresultaten u na afloop van de stage worden toegestuurd. Voor meer informatie mag u altijd contact opnemen. Alvast vriendelijk bedankt voor uw medewerking. Mw. Prof. Dr. Toine Lagro-Janssen

Helma van Osch, geneeskunde student Email: [email protected] Telefoon: 0613179537


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APPENDIX C: Case: GP suspects violence during work at GP Cooperatives “Once during my work at the GP Cooperatives, I was visited by parents with their young child of two years old. The child had a burn in the palm of its hand. The parents said it was an accident, and that the child had grabbed daddy’s cigarette while playing. However, the burn was clearly circumscribed, as it was caused by a cigarette that was pressed in the hand palm of the child. Furthermore, it was the only burn, concentrated on one place, there were no other burn marks on the child’s hand palm. I thought it looked like it was caused intentional, and not by accident. I told the parents I thought it was strange and that I didn’t trusted it. I told them I would report this to their own general practitioner. I mentioned it in the electronic report to their own general practitioner. I never heard from it again. However, recently, a few years later, I saw the child again, and all went well.”


Experiences of general practitioners in detecting domestic violence at General Practitioner Cooperatives: A qualitative study

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