ADViSE: supporting sexual health clinics to recognise and respond to domestic and sexual violence.
Date: 13 Dec 2023
Author: Charlotte Chappell
In this month’s eFeature, Charlotte Chappell of social enterprise IRISi tells us about ADViSE, a programme designed to support staff in sexual health settings to recognise and respond to people in their care who are affected by domestic and sexual violence.
ADViSE (Assessing for Domestic Violence and Abuse in Sexual Health Environments) is a programme developed by social enterprise IRISi to support staff in sexual health settings to recognise and respond to patients affected by domestic and sexual violence and abuse, offering direct referrals to specialist services. It serves as an excellent example of a service delivery model that aids medical workers in improving and ensuring their patients’ overall wellbeing.
Currently operating in Greater Manchester, Bristol, South Gloucestershire and London, the programme has already received over 800 referrals since its launch in 2021. Beyond the sheer volume of referrals, sexual health clinicians enrolled in the programme attest to its effectiveness:
"Previously I’d have suggested Rape Crisis, or the sexual assault referral centre, and said ‘take a photo of this number’. Having ADViSE is completely different: you are saying I can refer you to [this person], she works here, she really knows her stuff on this. It’s a person, not a helpline, and you feel so much more confident about encouraging [a patient].”
Domestic violence and health
The link between domestic and sexual violence and health is striking and clear. Women who have experienced domestic violence or abuse are:
- 2.3 times more likely to have issues with memory and concentration.
- 87% more likely to report pain or discomfort.
- 73% more likely to take pain medication.
- 86% more likely to take medication for sleep.
- 66% more likely to have been admitted to hospital for reasons other than labour.
(Potter et al 2020).
Studies also suggest that childhood sexual abuse has similar health impacts for male and female adult survivors (Springer, 2003). Interventions to provide support via identification in healthcare settings are clearly needed.
Sexual health settings are particularly important. People who have experienced domestic or sexual violence may attend clinics with unintended pregnancy, sexually transmitted infections, or other sexual health issues. It is important that sexual health staff feel confident recognising and responding to patients reporting domestic or sexual violence.
The ADViSE model has been developed based on IRIS (Identification and Referral to Improve Safety), a successful programme which has been running in general practice for a number of years.
The IRIS model has helped GPs to identify, ask, and refer over 30,000 patients, and has been established as the ‘gold standard’, referenced in British Association for Sexual Health and HIV (BASHH) guidance and recommended in Domestic Homicide Reviews. By harnessing the knowledge gained from this intervention, as well as adapting and honing it for sexual health settings, there is a real chance to offer patients more than they are currently receiving and bridge the gap between health and frontline domestic violence services.
An evaluation of a pilot programme in Bristol and East London found that the ADViSE model worked in sexual health settings, and was welcomed by staff and patients. After the training, sexual health staff said they felt confident asking about domestic violence and managing disclosures.
IRISI’s vision is a world in which gender-based violence is consistently recognised and addressed as a health issue, and our mission is to improve the healthcare response to gender-based violence through health and specialist services working together.
How ADViSE works
The National Institute for Health and Care Excellence (NICE) 2014 standards around domestic violence and abuse state that clinicians should:
- know how to ask about domestic violence and abuse
- know how to respond to disclosures
- refer survivors to specialist support services
- refer perpetrators to specialist support services.
ADViSE meets all the above in one streamlined, evidence-based package. It does not replace existing services; it is established within local service provision and so enhances and supports existing practice.
The ADViSE model builds on these principles by recruiting and training an Advocate Educator, based at a local domestic violence partner organisation, as well as recruiting and training a Clinical Lead who is based at the clinic. These two then deliver training to the rest of the clinicians, blending their knowledge and expertise. Training is also offered to reception and admin teams who are often the eyes and ears of the clinics and may see signs and behaviours before someone gets to the clinician.
Reaching a diverse range of patients
Anyone of any gender can be referred, regardless of who they are, when it happened, or what action they wish to take. The ADViSE worker thus has a more flexible remit than some more traditional domestic abuse services. The support offered can be client-led at the pace of the patient with no pressure to report or unsustainable timeframes. Being based at the clinic on certain days means that often a clinician can directly refer or offer for the Advocate Educator to meet the patient then and there. Advocate Educators can also be based at specific clinics. This has worked really well in Manchester within their Trans Clinic, for example, as by being present and building trust with patients and clinicians, referrals are being made and support given.
“I feel like I can start imagining what the future could be like.” -ADViSE Service User.
Based on a year of data from our referral cohorts in Greater Manchester, Bristol, and South Gloucestershire, ADViSE found that, of our service users:
- 60% had not accessed support (of any kind around domestic violence/sexual violence) before.
- 29% identified as LGBTQ+.
- 66% reported mental health issues (36% with a formal diagnosis).
- 93% reported male perpetrators, highlighting the need for a gender-sensitive approach even when broadening access.
We are very proud of our inclusive programme and training, and that we are reaching patients who have not accessed support before, and with a high proportion – compared to other programmes – of LGBTQ+ clients. We want to continue to work with marginalised groups and the single point of access really supports this intention.
“The programme has delivered so much more than we expected.” -ADViSE Trained Clinical Leads
We want ADViSE to grow in sexual health settings in the same way that IRIS has grown in general practice. We would like to trial ADViSE in different areas, such as more rural areas, or areas where there is no IRIS programme, and see if the programme can make a difference there. The resounding feedback is that when ADViSE is embedded, it’s like it has always been there and it seems absurd to go back to what was or wasn’t there before. The innovative model works – the Clinical Lead, the Advocate Educator, the training of clinicians and reception/admin staff, and the co-located skilled domestic violence worker who provides additional support to those who might never have disclosed. Now that we have begun this work, we need to continue to grow, evaluate and prove that, just like with IRIS, our interventions are gold standard, invaluable, and unique. Please help us to expand our work and ensure equity of access for patients.
“If ADVISE did disappear it would leave a big hole.” – ADViSE Trained SH Clinician
To find out more about the programme and how it can be implemented locally please contact Charlotte Chappell the ADViSE Lead and Senior Regional Manager at IRISi: Charlotte.Chappell@irisi.org
- National Institute for Health and Care Excellence (2014) Domestic violence and abuse: multi-agency working NICE guideline Available from https://www.nice.org.uk/guidance/ph50
- Potter et al (2020). Categories and health impacts of intimate partner violence in the World Health Organization multi-country study on women’s health and domestic violence. International journal of epidemiology, 1,11
- Springer et al 2003 The long-term health outcomes of childhood abuse. An overview and a call to action. Journal of General Internal Medicine. 2003;18:864–870
- Horwood et al (2018) Assessing for domestic violence in sexual health environments: a qualitative study Available from https://sti.bmj.com/content/94/2/88
- Sohal et al (2018), Improving the healthcare response to domestic violence and abuse in sexual health clinics: feasibility study of a training, support and referral intervention Available from https://sti.bmj.com/content/sextrans/94/2/83.full.pdf