Reaching everyone in general practice? Feasibility of an integrated domestic violence training and support intervention in primary care

Background Primary care needs to respond effectively to patients experiencing or perpetrating domestic violence and abuse (DVA) and their children, but there is uncertainty about the value of integrated programmes. The aim of the study was to develop and test the feasibility of an integrated primary care system-level training and support intervention, called IRIS+ (Enhanced Identification and Referral to Improve Safety), for all patients affected by DVA. IRIS+ was an adaptation of the original IRIS (Identification and Referral to Improve Safety) model designed to reach female survivors of DVA. Methods Observation of training; pre/post intervention questionnaires with clinicians and patients; data extracted from medical records and DVA agency; semi-structured interviews with clinicians, service providers and referred adults and children. Data collection took place between May 2017 and April 2018. Mixed method analysis was undertaken to triangulate data from various sources to assess the feasibility and acceptability of the intervention. Results Clinicians and service providers believed that the IRIS+ intervention had filled a service gap and was a valuable resource in identifying and referring women, men and children affected by DVA. Despite increased levels of preparedness reported by clinicians after training in managing the complexity of DVA in their practice, the intervention proved to be insufficient to catalyse identification and specialist referral of men and direct identification and referral (without their non-abusive parents) of children and young people. The study also revealed that reports provided to general practice by other agencies are important sources of information about adult and children patients affected by DVA. However, in the absence of guidance about how to use this information in patient care, there are uncertainties and variation in practice. Conclusions The study demonstrates that the IRIS+ intervention is not feasible in the form and timeframe we evaluated. Further adaptation is required to achieve identification and referral of men and children in primary care: an enhanced focus on engagement with men, direct engagement with children, and improved guidance and training on responding to reports of DVA received from other agencies. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-020-01297-5.

I am interested in hearing about your views and experiences of leading the domestic violence training. Although I have a list of questions, please do mention anything that you think is important that I don't ask you. If anything is unclear during the interview, let me know.

Consent checklist
Check participant: • Has read the participant information sheet • Understands that their participation is voluntary and that they can change their mind and withdraw at any time without having to give a reason and this won't impact on the support that they are receiving from the IRIS+ service. • Understands that if I have serious concerns about their safety, or that of any children they mention, that I may need to share this concern with an appropriate agency. • Understands that personal information about them (such as my name and address) will be treated with strict confidence and securely stored separately from all other data about them (e.g. interview transcripts). • Agrees that the anonymised information collected about them (anonymised transcripts) may be used to support the current research and relevant future research, and may be shared anonymously. Any questions?

Consent for recording
With your permission, I'd like to digitally record the interview. This is so the interview can be transcribed. It will be erased after being transcribed. All names of people or places which might identify you or others will not be transcribed. Are you happy to continue with the interview and for it to be digitally recorded?
The recording of the interview will be kept securely and only the anonymised transcript of that interview will be used within the research. The recordings themselves will be erased after transcription.
Can I just confirm that I have your consent to be audio-recorded while this interview takes place? I'll turn the recorder on now then, and for the record state:

Training delivery
Which training sessions did you deliver? − What elements did you focus on in delivery? − How comfortable and confident did you feel in talking about these topics? Did that change over time?
Who did you co-deliver the sessions with?
How well do you feel your co-delivery worked? What worked well? Why/why not?
− Do you think it was useful to have different professionals delivering the training? Why/why not?
How accepting were your audience that identifying and responding to DVA was/should be part of their job? If they weren't at the beginning, do you think that changed over the course of the training?
How responsive were your audience? − Were different clinicians / practices more or less responsive? Can you think of any reasons for this? (which professionals were attending, group dynamics) − Did the responsiveness of different groups of health professionals in your audience vary? How? Why? − Did they ask questions? − Seek out information if they did not understand/were unclear? − Raise any concerns or issues with the training? − Did they work well together during the group and pair exercises? − Answer questions when posed to the room?

From your perspective, did the format of the training work? What worked well/what didn't?
From your perspective, were there any particular exercises or delivery approaches that worked well or not so well? Why do you think this? Promptsvideo clips, group discussion, q and a, presenter delivering knowledge Thinking about the delivery of the training: What do you think could be improved? E.g. timing, duration, location, who delivers the training, type of delivery (e-resource, face to face)

Training content
Thinking about the content of the training: − Did you have a role in helping to develop the presentation slides or training material? Please describe. How successful do you feel the training was in supporting clinicians to identify and support children exposed to DVA?

What do you think worked well in relation to
− Why/Why not? − What do you think the barriers are to clinicians identifying this group?

How do you think the IRIS+ training and intervention can be developed to support clinicians in identifying DVA and making referrals to relevant agencies?
[Ask support workers/advocate educators]

Referral and first contact
Can you give a rough estimate of how many: • Women have been referred to your service by clinicians in the last (xx) months?
• Men have been referred to your service by clinicians in the last (xx) months?
• Children have been referred to your service by clinicians in the last (xx) months?

Have the numbers of referrals been what you expected? What surprised you? (if anything). Have they changed over time?
Can you describe how the referral process to your service works?
Did you receive adequate information?
Were the referrals appropriate?
What could be improved in relation to the referral process?

From your perspective, what are the barriers to clinicians referring to your service? (Explore in relation to men/women/victims/perpetrators/children as relevant)
Thinking back to when you made contact with adults who had been referred to your service: -How did the initial contact go? (e.g. was adult expecting contact to be made, had they remembered that referral had been made) -Did referred adults express any concern or annoyance at being referred to your service?
-If adults were not willing to meet with you or did not want further support, what reasons did they give (if any)?
-Were there any particular groups of adults who were not willing to engage further with your service? Why do you think that is?
[Ask children's support workers]: Thinking back to when you made contact with parents/carers about supporting their children/YP.
-How did the initial contact go? (e.g. was parent/carer expecting contact to be made, had they remembered that referral had been made) -Did referred parent/carers express any concern or annoyance at being referred to your service?
-If parent/carer were not willing to meet with you/did not want their child to be supported what reasons did they give (if any)?
Did you work with the safeguarding lead in each practice or someone else?
Did you work with clinicians in any particularly difficult or challenging situations?
Did you talk to clinicians over the telephone?
How often did you visit the different practices. Was it helpful doing so? Were there any challenges in relation to this?

Do you think having male and female victims and perpetrators to your service was successful?
Why/why not? (ask if appropriate)

Support work
I want now to turn to the kind of support that your service offers to adults and/or children, what that support looks like, how it was received by IRIS+ clients and how you think it could be improved. Thinking about your work as an Advocate Educator for the IRIS+ study, do you see clients most often: • For a one off appointment

• For regular appointments
Thinking about your work as an Advocate Educator for the IRIS+ study, what support have you offered and provided for (ask as appropriate): • Women who are victims of DVA Have children and young people needed or asked for support with things you could not help them with?
• If yes, can you give me some examples?
• What did you do in these situations (e.g. did you refer them on to other services etc) How do you think the children/young people responded to the support offered by your service?
What impact (both positive and negative) do you think your support has had on the lives of children/young people you have worked with? Can you give some examples?

Looking forward
How do you think your support service needs to develop to meet the needs of adults and children being referred by primary healthcare professionals?
How do you think your support service needs to develop for IRIS+ to be rolled out in the future?

Conclusion
Let the participant know that it's the end of your questions and ask them if there are any other comments that they would like to make.
Thank participant for their time.
*Please note this is a suggested guide for interviews only. In keeping with standard practice in qualitative research, these questions may be used selectively, and modified and added to as the study progresses and new themes or areas of interest emerge. We will also adapt this guide for use with different participant professional sub-groups and with participants at earlier or later stages of the study.
What could we do to improve the referral process from GPs and for other primary healthcare professionals?