National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

Background

The term ‘family abuse and violence’ (FAV) is used in this chapter to encompass domestic violence, intimate partner violence or abuse, the effects on children and perpetrator issues. Abuse and violence may involve physical, psychological, financial harms, social isolation, sexual abuse and violence, stalking, and use of digital technologies to inflict harm.¹ FAV is an important issue for the whole of Australian society; however, it is of particular concern to Aboriginal and Torres Strait Islander communities. Aboriginal and Torres Strait Islander women are 34 times more likely to be hospitalised due to family violence than non-Indigenous women, and FAV is the greatest driver of Aboriginal and Torres Strait Islander children being in out-of-home care.² The prevalence of violence against Aboriginal and Torres Strait Islander women is difficult to establish for many reasons. Despite under-reporting, surveys show Aboriginal and Torres Strait Islander women report higher levels of violence and suffer higher levels of injury and death as a result of family violence than non-Indigenous women.³ It is also important to recognise that the perpetrator may be non-Indigenous. The FAV prevalence rates are similar across all Aboriginal and Torres Strait Islander communities, with little variation by degree of remoteness.^4,5 Victims of FAV are unlikely to express their experience using explicit terms such as ‘family abuse and violence’.

Cripps reports^6,7 that Aboriginal and Torres Strait Islander victims are more likely to use ‘phases such as “um (pause) well we were arguing”, “my husband was acting up”, “he was being cheeky”, “it was just a little fight” and “we were drinking”’. Such terms are also used by perpetrators and community members, and may have a normalising effect, which leads to underestimating the extent of the problem.

Identifying family abuse and violence

Early identification of, and support for, individuals and families experiencing family abuse and violence is critical. Early intervention is a priority when there is a suspicion of violence escalating, and to prevent the recurrence and reduction of longer term harm.⁸ A healthcare provider is likely to be the first professional contact for survivors of intimate partner abuse or sexual assault,⁹ and consequently it is important that the health professional community is equipped with the necessary knowledge, skills and resources to intervene appropriately.

Women experiencing FAV may not seek help until their situation reaches crisis point; they may never seek help; they may leave and return to a violent partner multiple times; or they may not recognise or acknowledge that their experience is FAV.⁸ Victims may also present to healthcare providers with symptoms of depression, anxiety, insomnia, post-traumatic stress disorder, non-specific symptoms, pain, suicidal ideation, alcohol and other drug issues, and with other presenting complaints that appear to be unrelated. Health providers, therefore, need to be comfortable with asking if these symptoms may be related to FAV and to assess safety concerns for the victim and children.¹⁰ There is evidence that Aboriginal and Torres Strait Islander people are less likely to disclose FAV than non-Indigenous Australians, with one study finding that around 90% of violence against Aboriginal and Torres Strait Islander women was not disclosed.¹⁰ This highlights the need to talk about confidentiality and to ask about the possibility of abuse in a sensitive and empathic manner that takes account of the needs of children living in these families.⁵ Mandatory reporting may be required, depending on the type of abuse and legislative requirements in accordance with state and territory requirements.

It is also critical to be aware that perpetrators may also be presenting to care providers for other medical care, and there may be opportunities to discuss what is happening in the family and provide appropriate support for both perpetrators and victims. More information can be found in the RACGP Abuse and violence: Working with our patients in general practice (White Book) chapters specific to Aboriginal and Torres Strait Islander communities (Chapter 11) and to perpetrators (Chapter 5) (refer to ‘Resources’).¹¹ Aboriginal medical services and general practices are encouraged to discuss how to address these issues and to work out ways of making sure that the victim and perpetrator are being seen by different health practitioners. This is important for confidentiality and acknowledges that it is not possible for one person to safely care for both parties.

Interventions

Primary healthcare has an important role to play in dealing with FAV, particularly where early identification can trigger interventions that work by asking women about FAV and working with them around safety and management. This will involve primary healthcare providers accepting that they have a role, understanding the way patients may speak about what is happening,⁷ asking and working with safety, and being able to refer and coordinate care with other community services when appropriate.⁵ This may take time and is more like treating a chronic illness than a one-off intervention. Children can experience major harm from FAV, which can affect their development and can be a major contributor to future social and health issues¹² (refer to Chapter 3: Child health, ‘Preventing child maltreatment’).

There is limited high-quality evidence on the effectiveness of mainstream and Aboriginal and Torres Strait Islander–specific FAV prevention programs. Despite this, expert consensus has identified the following principles as being important for successful implementation of FAV interventions in Aboriginal and Torres Strait Islander communities:¹³

• community involvement, engagement and a strong acceptance; it is important to recognise that establishing meaningful community engagement can be a lengthy process
• consideration of cultural factors
• service delivery and program integration
• planning for long-term sustainability
• holistic focus and flexible approach.

Barriers to effective programs include:

• lack of integrated and coordinated service delivery practices
• expecting unrealistically large and rapid improvements
• over-simplistic policy frameworks to address entrenched issues
• operating with a lack of cultural awareness
• unsustainable responses that rely solely on short-term government funding.

If healthcare providers were to routinely ask all women about domestic violence (screening), this might encourage women who were reluctant to disclose their abuse to do so, or to recognise their own situation as abusive. A 2015 Cochrane review concluded that while screening led to an increase in the identification of intimate partner violence, there was no clear indication this increased referrals or women’s engagement with support services, or decreased such violence.¹⁴

However, the US Preventive Services Task Force recommended in 2013 that screening for intimate partner violence should occur for adult women who do not have signs or symptoms of abuse, and that women found to screen positive should be referred to intervention services. They found that the risk of harm from screening was small. They defined that all women were at potential risk for abuse but women of young age, with a history of substance abuse, marital difficulties and economic hardship, were at higher risk. An appropriate interval for screening was not able to be recommended. Several valid screening tools, with high levels of sensitivity and specificity, are available when screening for intimate partner violence. These include the Hurt, Insult, Threaten, Scream (HITS) tool, which asks four questions to ascertain if the partner is causing physical hurt, being insulting, threatening, or screaming/cursing at the victim, and scores responses according to a Likert scale.¹⁵

Kaiser Permanente (an integrated healthcare organisation in California with nearly four million patients) has demonstrated that making intimate partner violence assessments a ‘part of everyday care’ (through eHealth record prompts) has the potential to make a difference. Visible posters in clinics, routine enquiry and brief intervention are used. All patients that screen positive are referred to community services, many of which are onsite, and are provided with behavioural supports including safety planning, mental health supports and follow-up. Partnerships with local community organisations ensure referral systems for crises support, emergency shelter and legal assistance as well as women’s groups for support.¹⁶ The integrated attention needed to respond to family abuse and violence identified in primary healthcare settings may explain why studies in other US settings suggest limited improvements in the identification of partner violence, interventions and referrals from screening.¹⁶

Case finding, on the other hand, refers to actively asking women about FAV if they show signs of abuse or are in high-risk groups,¹⁴ or when they present with symptoms such as depression, anxiety, headaches, drug and alcohol abuse and many other issues with which FAV is associated. Rather than screening all women, it may be more effective to identify these women through a routine social history and then provide them with supportive safety planning, follow-up and referral when the person is ready.¹⁴

In view of the lack of good evidence that screening all women will produce better outcomes, case finding is the current recommendation.¹²
There is a stronger case for routine screening of pregnant women in Australia as FAV prevalence rates are higher during pregnancy.¹² In working to prevent FAV, family visits and programs for adolescents on healthy relationships are showing promise.^17,18 There is good evidence that early identification and intervention can help make victims and children much safer.⁹ There is also recognition that more intensive support needs to be provided to perpetrators, and several programs are now emerging to assist with this.^19,20 Health professionals need to be aware that the strongest risk factors for being a victim of physical violence are alcohol and other drug use by the perpetrator.²¹ Other risk factors are being in lone-parent families and experiencing financial stress.
FAV affects whole communities, hence the community and support services need to work together to find solutions. Programs that involve working with the whole community are essential, and several promising programs are emerging that take a community-based approach to FAV,¹³ such as spiritual interventions and working with communities to help individuals to heal from past abuse and violence.^22,23

Working with victims and perpetrators of FAV can place additional stress on primary healthcare providers, and it is important that health services have systems and protocols in place to ensure staff safety and support.^24,12