Primary care response to domestic violence and abuse in the COVID-19 pandemic: a rapid mixed-methods analysis (PRECODE)

Problem

Domestic violence and abuse (DVA) increased during the COVID-19 pandemic. During lockdowns usual routes to support and safety for people experiencing DVA were shut down or limited. In parallel, the pandemic required general practices to rapidly adapt to different ways of delivering care, largely shifting to remote consultations. Remote working has also extended to training and education.Primary health care professionals play a vital role in responding to patients affected by DVA and linking them to specialist DVA services. The PRECODE study explores the impacts of the pandemic (including these associated societal and clinical transitions) on how primary care has been providing support for patients affected by DVA during the pandemic period.

Approach

Using a rapid mixed-methods approach (interrupted time series and non-linear regression of daily referrals to IRIS DVA services from general practices in 33 areas in England and Wales; Interview- and observation-based qualitative study), the study explores the impact of the pandemic on DVA referral and patient support from primary care using practices engaged with the Identification and Referral to Improve Safety (IRIS) DVA education and referral support programme.

Findings

Referrals to DVA services reduced during the first national lockdown in 2020 compared to time periods before and after (27% CI=(21%, 34%), with 19% fewer referrals compared to an equivalent period the preceding year. These findings were compared with school holidays, another period of social closure, showing that during these times referrals for women experiencing DVA also reduced (2019 pre-pandemic school holiday 44%, 95% CI=(32%, 54%).We have conducted 19 semi-structured interviews with IRIS advocate educators, GPs, practice managers and primary care receptionists and have observed nine remote training sessions. Analysis of qualitative interviews highlights challenges identified by practices and adaptations they have made in transitioning to remote DVA training, and in identifying and supporting survivors. Key considerations included when and how to open conversations about DVA within remote consultations, achieving a safe space for disclosure, and acknowledging that patients may have limited safe periods to speak. Adaptations included having a low threshold for face-to-face appointments if there were DVA concerns and adapting how practices signal to patients that they are receptive to conversations about DVA.Remote training has improved access for GP staff, however, there have been challenges in training delivery, affecting engagement between facilitator and attendees.

Consequences

These findings demonstrate a need to ensure adequate access and support for those affected by DVA during potential future periods of lockdown, with relevance to other periods of social closure, such as school holidays. As the NHS emerges from the pandemic, remote consulting is likely to retain a prominent place in service delivery; it is critical to consider how this impacts on identification and support for patients affected by DVA.