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  • She just read the slides
  • 1.6 million deaths worldwide
  • Many more injured and suffer a range of health problems
  • Leading cause of death for 15 – 44 year olds worldwide
  • 14% deaths among males; 7% among females
  • One out of three women will be abused
  • 53 000 children murdered each year (WHO, 2013)
  • WHO declared it a public health issue in 1996
  • 4 – 12% of women beaten during pregnancy (WHO, 2011)

Outline of lecture

  • Definition
  • Typology
  • Why you should learn about violence
  • Global and national epidemiology
  • Ecological Model
  • Stages of change Model

Attitudes

  • In my family my dad controls all the finances and my mum has no say in how the money is spent mum has no say in how the money is spent.
    • Would you call that abuse?
  • In my culture men are considered the head of the household. Does this mean my mother is being abused?
    • Depends how you exert your power
    • If the man doesn't show it in terms of controlling the woman, then it's not abuse (be a benevolent leader)
  • Discuss what you think constitutes family violence?

Depends on culture and power.

Quotes

  • “He [husband] will not do anything to care for the kids. Will stay away... days and nights. When he comes home he will shout at me. Even the kids. He starts yelling... filth"
  • "She rarely goes out. Her husband will not speak to her for days if she goes to see her friends or to the youth club. Even to see her parents"

Relates to punishing someone by isolating them. This is violence. It is difficult to study violence from a public health perspective because of the definition of violence.

Definition

"Violence is the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation".

    • WHO definition
    • Includes intentional, likelihood of consequences and psychological and physical impact
  • Collective violence includes ethnic cleansing
  • We focus on interpersonal violence

Domestic/family violence: section 4(1) Crimes Act 1900 (NSW)

  • "Personal violence offence committed against a person who is currently or was previously linked to the perpetrator in the following ways:
    • Married in a defacto or intimate personal relationship
    • Living in the same household or residential facility
    • In a relationship involving his or her dependence on the perpetrator
    • A relative
  • Now includes more things from WHO definition

What is intimate partner abuse? WHO, 2002

  • IPV is defined as any behaviour within an intimate relationship that causes physical, psychological or sexual harm.

Such behaviour includes:

  • Acts of physical aggression – slapping, hitting, kicking, beating
  • Psychological abuse – intimidation, constant belittling
  • Forced intercourse and other forms of sexual coercion
  • Various controlling behaviours – isolating from family and friends, monitoring movements, deprivation of basic necessities.

Hitting is violence when it involves an imbalance of power.

Interpersonal Abuse(IPA)/ Domestic Violence (DV)/ Family violence (FV)

An abuse of power: the dominance of one person over another by physical/psychological means in intimate relationship.

Video

  • 3 tactics: isolation, sleep deprivation, financial control
  • Yelling, sleep deprivation, making sure she didn't allow her to go and do things on her own; isolating her, he had total control over money
  • Physical violence that she hid - she was ashamed
  • He was a big man, scared he would kill her (completely snap)
  • Drinking problem - he became explosive
  • She believed it would end; threatened that she would go to the police, he promised that he'd stop. He'd give her something after physically abusing her, but never apologised
    • "happy families" for a week or two

Model for why people stay in abusive relationships

  1. Honeymoon phase (enmeshment, denial of previous difficulties)
  2. Build up phase (increasing tensions - e.g. unplanned pregnancy)
  3. Stand over phase (control, fear; one partner below the other)
  4. Explosion (most likely physical abuse happens)
  5. Remorse phase (justification ("it's your actions that made me hit you"), minimisation, guilt)
  6. Pursuit phase (buy you back: pursuit and promises, helplessness, threats)
    • Victim feels "maybe this is the last time"
    • That's why people are unable to get out of it (especially if kids are involved)
    • Don't use it to blame the victim for not getting out of the cycle

Magnitude of family violence ‐ Australia

  • Leading contributor to death, disability and illness for Victorian women aged 15 – 44 years (VicHealth, 2005)
  • Costs 13.6 billion per year for Australian government (National council to reduce violence against women, 2010).
  • National survey (16,500 adults) 1 in 20 women experienced physical violence in previous year (ABS, 2006)
  • 15% women experienced DV since age 15 compared to 4.9% of men (ABS 2006)
  • 237,273 suspected child abuse cases reported during 2010 – 1011 (CFCA, 2012)
  • 2004: NSW police recorded 68,984 incidents of assault, 37.3% were domestic assaults ( p , (People, 2005).
  • 71.1% of domestic violence victims are women and 28.9% men (People, 2005)
  • Average prevalence rate of 4.6% elder abuse in Western Australia  = 12,500 victims. (Crime Research Center, 2011)

Problems with the data (underreporting):

  1. Just physical abuse in hospital (psych. not often recognised
  2. Change their story ("fell down stairs")

People may also believe that the police will not do anything, or the victim feels ashamed

Why are you learning about violence?

  • 1 in 10 women attending GP experience combined physical/emotional abuse last 12 months
  • Significant proportion of admissions to ED are victims of DV
  • Emotional problems can be symptoms of DV but go unrecognised
  • Abused women are more likely to disclose DV to their GPs
    • Doctors are in a good position for early recognition and helping it from escalating; and preventing violence from happening

How do women present?

File:DomesticViolencePresentation.png

Male patients who abuse

Presenting symptoms

  • Depression, stress, suicidal ideation
  • Alcohol or drug (licit or illicit) abuse
  • Anger problems
  • Relationship problems
  • Wife mandates behaviour change
  • Recent separation

Health outcomes of IPV

  • Abuse
    • Fatal outcomes
    • Non-fatal outcomes
      • Physical health
      • Chronic conditions
      • Mental health
  • Negative behaviours
    • Smoking (mental health + smoking = domestic violence)
  • Reproductive health

Eg. deafness, blindness, gastro disorders, IBS, somatic complains, obesity, depression, anxiety, PTSD, unwanted pregnancies, STIs

Ecological model showing shared risk factors for interpersonal interpersonal violence (WHO, 2004 p. 4) violence (WHO, 2004 p. 4)

What makes someone become an abuser?

  • Societal
    • Rapid social change
    • Economic inequality
    • Gender inequality
    • Policies that increase inequalities
    • Poverty
    • Weak economic safety nets
  • Community
    • Poverty
    • High crime levels
    • High residential mobility
    • High unemployment
    • Local illicit drug trade
    • Weak institutional policies
    • Inadequate victim care services
    • Situational factors
  • Relationship
    • Poor parenting practices
    • Discord
  • Individual

See diagram

From analysis to action

  • Primary prevention
    • Stop it in the first place
  • Secondary prevention
    • It has occurred, but you try to intervene to stop it continuing to happen and prevent complications (e.g. morning after pill, STD screening etc)
    • Law enforcement so the victim isn't subject to further violence
    • Screening for domestic violence
  • Tertiary prevention
    • Rehabilitate the person after complications have happened

Video

  • See the person by themselves; they will give you an interpreter if needed
  • Confidential
    • Unless safety of person or children is jeopardised
    • Then discuss it with the patient
  • Empathise with them
  • "have they hit/slapped you?" "how often?"
  • "are you frightened of your partner?"
  • "do you have someone you can stay with?" "I can provide somewhere for you to stay"

The starter is VERY important before asking the screening questions

  • "These are questions that they ask everyone" - so they aren't forming judgements; we ask this of every woman, not singling them out
  • "You don't have to answer, and what she says is confidentiality"
    • You discuss with the patient IF WELFARE HAS TO BE INVOLVED
    • It's NOT confidential if HER or HER CHILD'S life is in danger. You discuss it with her, let her know you're going to report it to police or community services, especially if you suspect there is child abuse
  • Build rapport

Three questions for screening: see tutorial

From analysis to action

  • Interventions at societal, community, relationship, individual levels
  • Societal: more lighting in the area; legislative changes to improve economic situation of people. Need well-established laws to deter people
  • Community
  • Relationship
  • Individual

Stages of change model

  • Precontemplation: patient doesn't realise that abuse is happening. In this stage, you don't talk to them about leaving the partner or educate them about DV. All you do is to develop the link between their presenting problem and DV
  • Contemplation: they realise that DV is a problem; you educate here
  • Determination: person says they need a change - positively disclose that they're in DV
  • Action: they want to leave abusing relationship (e.g. involve police etc). "Practice leaving" - where would you leave the key? Save money, keep it in secret place, etc.
  • etc etc

Resources/referrals

  • MUST READ, IN EXAMS. RACGP document is good.

Take home messages