Study Protocol - Computer Assisted Enquiry for Experiences of Domestic Abuse in Health

Study Protocol - Computer Assisted Enquiry for Experiences of Domestic Abuse in Health Care Setting

April 2010

1. Introduction

The term Gender-Based Violence (GBV) describes violence that is directed against a woman because she is a woman or violence that affects women disproportionately. It includes acts that inflict physical, mental or sexual harm or suffering, threats of such acts, coercion or other deprivation of liberty(United Nations 1992). Domestic abuse is one form of gender-based violence. The Scottish Government defines domestic abuse as “perpetrated by partners or ex-partners [which] can include physical abuse (assault and physical attack including a range of behaviour), sexual abuse (acts which degrade and humiliate women and are perpetrated against will, including rape) and mental and emotional abuse (such as threats, verbal abuse, racial abuse, withholding money and other types of controlling behaviour such as isolation from family and friends).

The consequences of domestic abuse are well documented and include substantial morbidity and mortality, physical and psychological health problems(Krug et al 2002). It is a significant public health problem(WHO). In 2008 the Scottish Government introduced the National Domestic Abuse Delivery Plan for Children and Young Peopleas part of a strategy to address this. A key component of delivery plan is the introduction of routine enquiry of domestic abuse in healthcare settings.

The National Gender-based Violence and Health Programme was created to progress this work and aims to improve identification of and responses to gender-based violence across NHS Scotland. Routine enquiry will be implemented in priority healthcare settings (maternity, substance misuse, mental health, sexual health, emergency medicine and community nursing). Routine enquiry means asking every new person presenting to services specific questions about experiences of abuse. As health care workers are often the first or only professional contact that people experiencing abuse have, they can offer a lifeline to safety (DoH 2005) and have a responsibility and opportunity to act (Gunter 2007, Campbell 2003, Sharps et al 2001).

Routine enquiry provides an opportunity for women to disclose experiences of abuse and access additional supports to address the consequences of abuse(Feder et al 2009, Seng 2008). Disclosure enables health care workers to incorporate the impact of abuse in making a diagnosis and creating treatment and care plans(Zink 2004). However, research has shown that even when women choose not to disclose the act of being asked can in itself be beneficial(Leibshutz 2008). Routine enquiry reduces stigma around the issue of abuse, informs service users of health consequences of abuse and the role that health care workers can play in responding to this(Stenson 2005, Chang et al 2004, Zink et al 2004). Routine enquiry may also help some women to identify the presence of abuse in their lives(Ulrich 2006, Campbell 2004).

Routinely enquiry is acceptable to service users (Feder et al 2009, Gunter 2007, McDonnell 2006)and has been shown to increase their satisfaction with services(Leibshutz 2008, Rodriguez 1996). Routine enquiry commonly takes place during face to face assessment interviews. However, computer assisted routine enquiry has also been shown to be acceptable to service users and to facilitate disclosure to health care workers(Ahmad et al 2009, Feder et al 2009, Renker 2007, Trautman et al 2007, Rhodes et al 2006, Bacchus et al 2004, Gerbert et al 1999.) Computer assisted routine enquiry (CARE) provides anonymity for respondents. This could have particular significance in rural areas where service users have concerns about confidentiality following disclosures of abuse (McCarry & Williamson 2009).

As with face to face enquiry if service users choose not to share information with healthcare workerstheir experience of abuse and risk of further abuse cannot be incorporated into care planning, however, computer assisted routine enquiry can still fulfil the role of raising awareness, reducing stigma and promoting the role of health professionals in responding to abuse.

2. Computer Assisted Routine Enquiry

The Computer Assisted Routine Enquiry (CARE) programme has been developed by Scotland’sHealth on the Web (SHOW) Development Team and the National GBV & Health Team. The full programme content is available in appendix 1. There are 6 sections and the programme should take no longer than 10 minutes to complete.

1)Introduction to programme and study

2) Learning to use touch screen computer

3) General questions (e.g. age, children etc)

4) Routine enquiry for domestic abuse

5) Questions about abuse and information (This section is only for women who disclose in section 4)

6) Evaluation of CARE

The programme is designed to be as user friendly and accessible as possible. It will be delivered through a touch screen tablet and will incorporate video clips and audio stream. Each response option will be highlighted in turn to help users select the most appropriate response for them. Women will also have the option to exit the programme at any time and move on past questions which they do not wish to answer.

It is essential that women are left in private to complete the CARE Programme and therefore, CARE is not appropriate for use in the service user’s home.

3. Aims of this study

This studycompares the effectiveness of computer assisted routine enquiry of domestic abuse in identifying service users’ experience of abuse and facilitating disclosure to healthcare workerswith routine in person, face to face enquiry.

4. Research questions

• Does computer assisted enquiry about domestic abuse overcome barriers to disclosure by providing anonymity for respondents in rural and urban areas?
• Does computer assisted enquiry about domestic abuse facilitate disclosure to health care workers?
• Is computer assisted routine enquiry of domestic abuse acceptable to service users in Scotland?
• What are the characteristics of women who choose to disclose following computer assisted enquiry and / or health care workers? (Age, ethnicity, severity of abuse)

5. Methods

5.1 Study Design

This is an experimental multi site study. Participants will be randomly allocated to two groups: usual face to face routine enquiry (usual care group) or computer assisted routine enquiry (CARE Group). An experimental design enables comparison between rates of disclosure in usual care and CARE groups and random allocation will reduce selection bias.

5.2 Study sites

This study builds on the work undertaken within each health board area as part of the National GBV & Health Programme. Implementation of routine enquiry is incremental and each Board has identified initial sites within maternity and mental health services to implement routine enquiry with all new patients. Rural and urban study sites have been selected to identify potential differences between these settings.

The following sites have been identified:

5.3 Study sample

An opportunist sample will be drawn from maternity and mental health services where routine face to face enquiry of domestic abuse has already been introduced. In rural areas all new female patients will be invited to participate. Only female patients will be included in this study because at present, the evidence base does not provide clear direction on helpful responses for men who experience domestic abuse. However, the study would not preclude workers from asking male service users about domestic abuse if they thought it appropriate as in usual practice.

In urban areas, researcher resources may limit the ability to invite all new female patients to participate. A random sample of service users will be selected from clinic lists and invited to participate in this instance.

Sample sizes are dependant to some extent on the support and participation of study sites. Potentially data collection in rural areas could run for a period of months. Flexibility of data collection is essential at this stage to ensure as large a sample as possible. However, it is anticipated that a total sample of at least 200 service users will be achieved in the data collection period (50 rural maternityservice users , 50 urban maternity service users, 50 rural mental health service users and 50 urban maternity service users.) As previous studies have compared computer assisted enquiry to selective enquiry or spontaneous disclosure it has not been possible to do power calculations for this study.

Inclusion criteria: Participants must be female, aged 16 years or older and be considered clinically well to participate by workers. As the CARE Programme is being developed for this studyare limitations on this version of the programme, requiring participants to be fluent in English language and physically able to use a mouse / touch screen computer. In addition participants must be able to either hear the accompanying audio stream and or read the accompanying subtitles.

Studies in the USA(Renker et al)have developed computer assisted self interview specifically for women with disabilities andtranslation to other languages could be facilitated. This could be explored in subsequent studies if CARE is recommended as part of usual care. Ethnicity and disability data will be recorded for service users participating in this study, as will reason for exclusion data.

5.4 Procedure

The diagram in Appendix 2 describes the process for data collection in both “usual care” and CARE groups.

Preparing study sites

The research manager will visit each study site to introduce the study aims, processes and tools. At this session the workers will agree data collection time scales and plan the most efficient schedule for data collection (for example where possible arranging for all new patients to attend on one or two days per week in rural areas).

• Recruitment to study

A healthcare worker will review all new patient records prior to clinic session commencing and identify any women where it is indicated that discussion of the study would not be appropriate due to health reasons to the fieldworker. The fieldworker will review the remaining new patient records to ensure that it is appropriate to discuss the study with the woman. If women meet the inclusion criteria the fieldworker will provide written information (Appendix 3) and inform them of the following:

• All new female patients are being invited to participate.
• The study is trying to find the best way to ask about things that affect our health.
• Participation is entirely voluntary and the care that women receive will not be affected by their decision to participate or not.
• To participate women will be required to either answer questions about routine care at the end of their visit by questionnaire which will take 5 minutes to complete or use a computer to answer questions which can take around 10 minutes to complete. If women agree to participate they will be allocated to one of these groups.
• The computer programme has been designed for the public to use and you do not need to be good with computers to use it.
• Responses are completely confidential unless the women choose to share information with healthcare workers. If they choose not to share information then no-one will know how they have responded.
• Women will not be required to become involved in follow upor any other activity.
• They can exit the study at any time.

Data collection

If consent is obtained the fieldworker will:

• Advise the woman that if there is anything they wish to speak about following the assessment visit the fieldworker will be available in the clinic setting and contact details will be provided on the written information for women to contact the fieldworker at a later date if necessary (Appendix 3).Numbers for national services are also provided in the information packs. Unless contacted by the service user, the fieldworker will have no further contact with the woman during this visit.
• Obtain written consent from woman (Appendix 4)
• Allocate women to usual care or CARE group alternately.
• Inform the healthcare worker whether usual care or CARE is required during this assessment and give the healthcare worker data collection form(s) for completion at the end of the assessment visit.
• If allocated to CARE group, set up ready for use.

OR

If women decline to participate or do not meet the inclusion criteria the fieldworker will:

• Thank the woman for taking time to hear about the study.

• Inform the healthcare worker that face to face routine enquiry is required during this visit as per “usual care” and give healthcare worker data collection form for completion at the end of assessment visit. No further action is required for women who decline to participate.

Usual Care Group

In the usual care group, face to face routine enquiry will take place. Health care workers will ask service users direct questions about domestic abuse during the assessment interview. Data collection in this group aims to identify if enquiry does routinely occurand if anonymity is an issue for patients and staff.

At the end of the assessment the healthcare worker will again explain the study to women and give the following information.

• All women attending the clinic for their first visit are being invited to participate.
• Questions are about routine care in this area
• Participation is entirely voluntary.
• The care that women receive will not be affected by their decision to participate or not.
• They are being asked to complete a questionnaire which will take no more than 5 minutes to complete.
• Responses are completely confidential.
• Women will not be required to become involved in follow up or any other activity.

Women who wish to continue will be given the usual care service userdata collection form (Appendix 5) and left in a private space to complete the questionnaire (either consultation room or a separate private area). Partners or others accompanying the woman will be asked to wait in the waiting area. Envelopes will be provided for the completed questionnaires and a box will be placed in the private areas for the collection of envelopes. If women decline to participate at this point the visit will conclude as usual.

• Healthcare worker– usual care

When the consultation is completed, the healthcare worker will complete the data collection form (Appendix6) whether women completed data collection forms or not. This will be placed in an envelope and left for collection in a box with other responses.

Implications for workers providing usual care:

• Health care workers will be advised by fieldworkers about the method of routine enquiry required.
• Healthcare workers will be required to briefly describe the study to all new patients at the end of each visit.
• Following each new patient assessment workers will be required to complete the worker data collection form. This should take approximately 1 minute.
• Areas are required to provide a private space where women can complete the data collection forms.

Computer Assisted Routine Enquiry (CARE)

Data collection in the CARE group aims to assess the effectiveness of CARE in facilitating disclosure, gathering information on characteristics of those who do disclose, measuring the frequency of face to face enquiry of abuse following CARE and gathering the views of service users and staff on anonymity and service users’ views of using CARE.

• Introducing Computer Assisted Routine Enquiry

The fieldworker will advise healthcare worker that CARE is required and if necessary set up equipment prior to assessment commencing. The healthcare worker will introduce themselves to the woman as usual and take them to the assessment room. When routine enquiry would usually be introduced (for example during private time or during relationship / family assessment) the healthcare worker will remind women of the study. They will indicate how to start the programme, advise the woman to open the room door when the programme ends and leave them alone to complete the CARE programme. They will return to the room when women have opened the door to indicate that they have finished.

• The CARE Programme – Enquiry and disclosure

The programme content is detailed in Appendix 6. To ensure that all women participating in this study are asked about domestic abuse and given an opportunity to disclose the following features have been included in the programme:

If women exit the programme before routine enquiry has been achieved notification of this will be printed out in the room stating “Routine enquiry please, exited programme before routine enquiry achieved.”

If women do not disclose personal experience of abuse but wish to speak with healthcare worker about abuse a print out in the room will state “Please discuss domestic abuse – no disclosure.”

If women do disclose and choose to share this information with healthcare workers then a print out in the room will state “Please discuss domestic abuse – disclosure.” This will also provide any additional information that women provide about the abuse.

Whether women do or do not disclose during the CARE programme, if they choose not to share this information with workers no print out will be made.