Perinatal care

August 2016

Research

Setting up a domestic violence telephone helpline for general practitioners in Australia: What exists and what works?

Volume 45, No.8, August 2016 Pages 594-599

Kirsty Forsdike-Young

Kelsey Hegarty

Background

Domestic violence is a global health issue. The World Health Organization (WHO) recommends training health professionals to respond appropriately to victims of domestic violence. Despite those who experience domestic violence attending general practice, general practitioners (GPs) receive little training in managing this issue. Helplines predominantly exist to support the general public and patients; however, few exist for GPs, and there are none regarding domestic violence.

Objective/s

This article explores how helplines can support GPs in the management of patients who have experienced domestic violence.

Methods

A scoping review of helplines targeting GPs was used in this study.

Results

Few helplines target health professionals and limited evaluations on these helplines have been undertaken. Health professional helplines cover broad specialist fields, and health professionals value access to specialists. Helplines are educational and increase the confidence of health professionals in providing quality patient care. Key challenges include helpline awareness and timely support.

Discussion

Developing a domestic violence helpline for GPs is unexplored, but there is potential for education and improved response to patients. Helpline workers need tailored training to respond to health professionals’ complex, specialist needs. These helplines need extensive marketing to ensure uptake and funding.

Domestic violence1 is an internationally recognised global health issue2 that Australia has prioritised.3 The prevalence of domestic violence in Australia is alarming – 17% of women and 5.3% of men have experienced partner violence since the age of 15 years,4 and one woman a week, on average, has been killed.5 Domestic violence is associated with several health issues, including mental health disorders, chronic pain and irritable bowel syndrome.6 General practice is often the first port of call for women who experience domestic violence; general practitioners (GPs) can see up to five of these women a week.7

The World Health Organization (WHO) has found that domestic violence training for health professionals is scarce. The WHO recommends that training should go beyond identifying victims of domestic violence to providing appropriate responses and referrals to existing services for ongoing support.6 In Australia, however, such training in medical schools is rare8 and GPs must proactively enrol in additional education to fill knowledge gaps. Such education is provided by The Royal Australian College of General Practitioners (RACGP) through the Abuse and violence: Working with our patients in general practice (the White Book)9 publication and gplearning online active learning modules. Primary Health Networks (formerly Medicare Locals) also facilitate training for local practices.

Telephone information and support lines (helplines) exist throughout the healthcare field. Such helplines can be relatively cheap to operate, easily accessible and are run by paid professionals or volunteers. They exist predominantly for patients, carers and the general public. One of the largest, most well-known helplines is the nurse-led NHS Direct in the UK (replaced by NHS-111 in 2014). The Australian equivalent is healthdirect, which provides patients with access to GPs via telephone out of hours on weekdays, and on weekends and public holidays. Other helplines exist for broad areas of health such as smoking and alcohol quit lines, cancer care, and human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS).

There are several domestic violence helplines in Australia and internationally. The Australian helplines are provided either nationally, such as 1800RESPECT, or are state-based or territory-based. Their primary target population is victims of abuse, but they may also provide support to friends, families or carers. There is no helpline solely dedicated to GPs or other health professionals whose patients may be experiencing domestic violence. However, 1800RESPECT and the Men’s Referral Service encourage professionals to contact them for support. Overseas domestic violence helplines are similar, their target population being those who have experienced domestic violence. However, the UK National Domestic Violence Freephone Helpline and SupportLine, and US national Love is Respect (a dedicated service for young people) and state-based Women Helping Battered Women helplines are also available to professionals.

While there is no dedicated domestic violence helpline for GPs or other health professionals, there are several helplines in Australia and internationally that seek to support health professionals in other areas of patient care. The majority of these helplines in Australia are state-based or territory-based. They cover a wide range of health-related issues and advertise themselves as covering areas such as care management strategies, referral pathways, risk assessment, education, treatment options, medical issues and guidance on conversations with patients.

The aim of this paper is to report on a scoping review undertaken to see what helplines exist for GPs, and what evaluations have been done to explore the unique challenges and opportunities that may exist in their successful delivery. The research question used to frame the review was: ‘How can a telephone information and support line best support and respond to general practitioners?’ The review will provide background to underpin consultative stages in the development of a helpline to support GPs in their work with patients experiencing domestic violence.

Methods

We followed Arksey and O’Malley’s five-stage scoping review methodological framework, as refined by Levac et al.10,11 After identifying our research question, we identified relevant studies by searching electronic databases, reference lists and existing networks. We searched Medline, Pubmed, Cinahl and PyscINFO using terms relating to a telephone helpline (Table 1) and evaluation in varying combinations. The year of publication was not restricted. As there is a paucity of helplines targeting GPs, and differing terms used in Australian and international academic literature, we searched for helplines supporting a range of health professionals. We will refer to health professionals in this review unless GPs are specifically referenced. We then searched reference lists for any additional relevant papers. We also consulted with existing networks to identity any further studies of Australian-based helplines undertaken in relevant healthcare fields (eg mental health).

We selected studies based on specified inclusion criteria. Evaluations were included if the studies were published in English and were of a telephone line that targets health professionals or that health professionals can contact. Details of the study population and type are shown in Table 1. Evaluations that solely targeted non-health professionals were excluded.

While we only reviewed telephone helplines, we realise that alternative technological pathways to information and support exist. The Dutch AIDS and Sexually Transmitted Infection public helpline provides email access,12 whereas the Rape, Abuse and Incest National Network (RAINN), the national sexual assault helpline in the US, has an online support facility.13,14 Despite this, a telephone is still the most accessible and broadly accepted form of communication and remained the focus of this review. We charted key items of information from the selected studies, including the type of helpline, target population, evaluation methods and results. We then undertook a qualitative content analysis.

Results

Thirty-nine papers were found and 21 were deemed eligible for review. Of those excluded, the majority reported evaluations of helplines that solely targeted non-health professionals, were not telephone helplines, and where the focus was not the helpline itself (eg one paper reported on an evaluation of an educational program for telephone advisors). An additional six papers were found through reference list searches of eligible papers. A total of 27 papers (Appendix 1, available online only) were deemed eligible for inclusion in this review.

Table 1. Search terms and inclusion criteria

Telephone line

Study population

Study type (evaluation)

Hotline Helpline
Support line
Liaison line
Warmline
Advisory service
Consultation-liaison

Health professional (eg primary care,
physician, nurses, health worker, psych, allied health, general practitioner)

Randomised controlled trial
Cross-sectional
Before and after studies
Audits
Qualitative/quantitative

Target populations

The majority of published papers evaluating helplines are those targeting patients or the general public. There were some evaluations of helplines that health professionals accessed, even though they were not the primary population.15–23 There were three exceptions:

  • a Ugandan warmline that supports antiretroviral therapy program, where the majority of callers were field staff and peer health workers (69%; n = 501)24
  • the US National Immunization Information Hotline, which reported that one-third of all callers were health professionals (34%; n = 11,868)25
  • rheumatology helplines across several hospital sites, which are aimed at health professionals and patients. Health professionals formed 21% (n = 112) of callers responding to a survey.26

There were few published evaluations of helplines solely targeting health professionals.27–38 With the exception of the Ugandan warmline,24 health professional callers accounted for less than 20% of calls.15,19,20,24,39 Both the helplines and studies that evaluated them suggest health professionals are often secondary to the patients or general public.15–18,21,22,39 However, Jefford et al22 concluded that considering the number of calls made by health professionals, more research needs to be done to understand their needs.

The topic areas of the helplines were broad (Table 2) and the type of health professional callers was not always specifically identified, either because of data collection methods or limited reporting of results. However, some evaluations did specify that the helpline was targeted at or accessed by GPs.15,19,20,27,32–34,38

Seeking information and advice

The reasons for health professionals accessing helplines vary depending on the service provision marketed. However, calls were predominantly made to seek general or specialist information, or advice regarding specific patients.15,17,24,28,32–35,37,38 Health professionals value the opportunity to speak to a specialist about a specific patient during a consultation, requiring immediate accessibility.38 Such advice ranged across care or treatment logistics28 and information materials or services available.22 Broader questions, not patient-specific, were also asked (eg regarding HIV or cancer care generally).20,21,24,28,33,34,36,39

Complexity

Several evaluations found that health professionals could ask about multiple issues that were broad in scope during one call.16,20,27 Queries across helplines for palliative, cancer and rheumatology care were as wide-ranging as psychological, social, organisational and patient management.20,22,26,27,39 Health professionals seek expert advice in complex cases, particularly in areas such as mental health.33,35,38

Educational opportunities

Some evaluations found that the helplines offered, and should offer, more than information and referral. The purpose of Counselling and Diagnosis in Dementia (CANDID), a telemedicine service supporting the care of young patients with dementia, was that it should be ‘more than a simple source of information … that it should have the ability to influence and alter the care and management’ of patients. The service also aimed to provide a ‘holistic approach, liaising with professionals and family members, providing advice on the practice, social and legal issues of these diseases as well as the medical aspects’.19

Evaluation of the Cancer Information Service in the US found that helplines could be used proactively to disseminate information on prevention and control, and assist callers to overcome barriers to action.39 GPs who used a mental health helpline in South Australia that gave them access to psychiatrists found that the advice they received increased their knowledge of mental health, relevant services and confidence in managing patients.33 Helplines also had educational potential32,33,40,41 or highlighted knowledge gaps.31 Furthermore, advice received was used in subsequesnt situations that were similar, suggesting ongoing education.28,33,34 The potential usefulness of helplines for health professionals is enhanced if they form part of a coordinated program that also provides training and peer support.29,32

Opportunities for health professionals: Confident provision of quality care

Evaluations suggested that as advice given to health professionals was often followed,27,33,34 there was a potential for improved quality of care.24,27,28,35,37 A helpline could also enable a health professional to feel assured of their patient management skills when faced with a difficult clinical situation.39 Helplines appeared to meet the consultation needs of health professionals28,33,35 and made their jobs somewhat easier.24 A helpline run by health professionals for health professionals can also lead to additional problems being revealed that were not necessarily the initial focus of the call. One evaluation showed the importance of a helpline’s potential for exchange of thought.27

Table 2. Topics covered by helplines for health professionals

Topics

References

AIDS/HIV

16, 24, 28, 31

Drug and alcohol

21, 23, 34, 36

Cancer

17, 22, 39

Palliative care

15, 27, 35

Rheumatology

20, 26

Infectious disease

40, 41

Mental health

33, 38

Multiple sclerosis (MS)

18

Youth dementia

19

Antibiotic treatment

29

Geriatric care

32

Perinatal HIV care

37

Immunisation

25

Barriers and challenges to a successful helpline for health professionals

While some health professionals expressed a need for helplines,25,38 there were some key barriers and challenges in providing a successful helpline. The biggest issues related to awareness of the helpline and timely availability of advice. Evaluations also reported slow uptake33,38 or low levels of ongoing use. An evaluation of a pilot psychiatric telephone advice line in New South Wales found a slow uptake by GPs.38 Despite low levels of use, GPs who responded to the post-pilot survey said they wanted the service to continue. Interestingly, neither those who used the service (71%; n = 5) nor those who had not used it (86%; n = 42) had knowledge of a national helpline (GP-Psych Support), run by the RACGP. This RACGP helpline was similar to the pilot, but no evaluation had been published and it was discontinued in 2014.

The evaluation of CANDID, a service available to patients, their families and health professionals, identified a less than anticipated use by health professionals, suggesting that greater promotion of the service is required.19 Antibiotel, a helpline for advice on antibiotic treatment as part of the Antibiolar Lorraine antibiology network in France, also experienced low levels of usage.29 A helpline that provides support for nurses and GPs of a hospital and rest home for aged care experienced low levels of use, potentially because the nurses opted to seek advice from more senior staff and the GPs were able to frequently access a geriatrician face to face. However, senior staff members did use the helpline and saw it as ‘back up’.32 Sometimes, health professionals were not aware of the service at all,28 used alternative resources,34 or did not see the helpline as a legitimate resource.30 Promotion was found to be vital for uptake,19,24,34 with usage potentially dependant on media attention.41

Non-timely availability of advice was usually a result of intermediaries taking the initial call or callers having to leave messages on answering machines, and delays in referring to and receiving call-backs from specialists.24,28,34 GPs preferred instant access to a specialist, with the patient still in the consulting room.38 However, a broader range of health professionals found it acceptable to receive call back within one day.26

Another key challenge related to training helpline workers. One evaluation identified the complex role of helplines, particularly the diverse support and information often provided.17 The needs of helpline users had to be monitored frequently and training tailored accordingly.16,22 As such, training and the expertise of those running the helpline needed to be consistent with well-defined protocols.20,24,30 Training may need to be intensive, particularly considering the broad range of topics covered and a general question found to be less satisfactorily answered than a specific question.16 In some cases, a specialist answering the helpline was preferred.26

Discussion

Although there is no existing domestic violence helpline for health professionals, the literature reviewed showed that helplines developed to assist health professionals, directly or alongside a broader target audience, do exist in other niche fields where access to expert specialist advice is required. There is a scarcity of published research on helplines directly targeting GPs. However, there are similar components of successful helplines that target various health professionals. There are certainly some aspects of helplines targeting patients or the general public that may be relevant to a discussion on developing a helpline for the specialist area of domestic violence.

Key considerations in developing a helpline will be who should answer the helpline and what level of information or advice is required by the caller and marketed as being available. There needs to be sufficient training for all potential calls. The categories of calls can be very broad, from patient-specific advice that is required immediately to general information on the topic area. These categories can also be specific medical advice or emotional, social and psychological support. A domestic violence helpline would, no doubt, require a similarly broad level of information and advice.

With regard to helplines for callers who are not health professionals, a study that evaluated a national sexual assault online hotline found that users rated the volunteers as lacking in knowledge and skills.13 Furthermore, where helplines target different groups (eg the general public, patients and their carers), the needs of each group are often different and responses need to be tailored accordingly.42 Even within one health profession, the level of experience between callers may differ (eg general practice registrar and GP with decades of experience, or a more generalist GP and GP specialising in mental health). It is not known whether health professionals would prefer a locally specific helpline or one targeting health professionals nationwide. Certainly, GPs often have a network of local specialists they ring for advice. This suggests that the provision of a locally tailored support structure may be more acceptable to this target population.

With a broad range of knowledge and level of specialist skill required, training needs to be tailored to the target caller population. Reviews of helplines targeting callers who are not health professional suggest training may include the following:43,44

  • improving knowledge and skills
  • raising confidence to provide support
  • increasing awareness of available tools for callers
  • being explicitly informed that such support is part of the helpline’s services.

Training can be in the form of case scripts, but they must show an accurate portrayal of the type of problems helplines support.45

Helplines can be used as educational tools and provide care beyond the immediate topic area. Using a helpline as an educational tool for the dissemination of health education and promoting health behaviour change has been cited as a ‘promising strategy’ for the general public and patients.46 A study evaluating the effectiveness of helpline services for victims of domestic violence in the US showed, inter alia, that these services provided additional information. This study suggested that it was not just information about domestic violence that callers received when accessing services, but issues as wide-ranging as homelessness and poverty.47 A helpline has the opportunity to educate health professionals about domestic violence and the broader implications for their patients.

Aggressively marketing a helpline to health professionals, particularly GPs, is crucial. Even with extensive research and planning, helplines may not be successful in terms of usage rates. One study on smoking cessation for patients suggested that 1–2% of targeted population is a reasonable expectation for participation rates.48 The GP-Psych Support helpline was discontinued because of a lack of funding. In a letter to the editor, Bradstock et al commented that GPs had been satisfied using the service, that it had increased GPs knowledge, and they would consider using it again.49

The issue of a lack of funding was raised by Fountain-Polley et al regarding a paediatric rheumatology helpline for families and health professionals.50 The challenges for specialists providing helplines are ensuring sufficient recognition for the significant workload involved, and that the service being used is valued in order to secure funding.50

One of the key limitations of the papers reviewed was a lack of quality formal evaluations. The methods used by the studies reviewed were relatively weak. There was also a lack of detailed demographics (eg gender, location, type of practice) and spectrum of the needs of health professionals. As such, the outcomes of helplines for subgroups of health professionals were often unknown. Further, a rigorous evaluation of any helpline should include an analysis of cost-effectiveness and, ideally, some measurement of how many patients were assisted by the health professional, and how much access to information and support increased.

Conclusion

There is a paucity of good-quality evaluations of helplines for health professionals. Potential exists for a helpline to support GPs in their work with patients experiencing domestic violence. However, a number of key areas need to be understood, including the specific needs of GPs. Furthermore, a helpline could contribute to the education of GPs in this complex area. However, any helpline established may require extensively tailored protocols and trained helpline workers to adequately respond to a potentially broad range of requirements from basic information and how to provide an appropriate first-line response, to referrals for housing and financial support. It is clear that a helpline would need to be comprehensively marketed to ensure sufficient uptake, not only to successfully satisfy needs, but also to secure future ongoing funding and availability.

Authors

Kirsty Forsdike-Young BA (Hons), PgDipLaw, PgDipLegalPractice, Senior Research Officer, Department of General Practice, University of Melbourne, Carlton, VIC. k.forsdike@unimelb.edu.au

Kelsey Hegarty MBBS, FRACGP, DRANZCOG, PhD, Professor, Department of General Practice, University of Melbourne, Carlton, VIC

Provenance and peer review: Not commissioned, externally peer reviewed.

Acknowledgements

This project was funded by the Australian Government Department of Social Services.

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Correspondence afp@racgp.org.au

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