The HARMONY trial: assessing general practitioner knowledge, attitudes and confidence following culturally safe domestic violence and abuse training
Molly Allen-Leap A * , Angela Taft A , Felicity Young B , Leesa Hooker A B Kelsey Hegarty C DA
B
C
D
Abstract
Domestic violence and abuse (DVA) impacts all communities, including migrant/refugee populations. Although general practitioners (GPs) are often a first point of contact for victim-survivors, most lack training in culturally safe responses to DVA.
We evaluated culturally safe DVA training (HARMONY), co-delivered by a GP educator and bilingual South Asian DVA advocate, to general practice clinics in Victoria, Australia. The program included clinical audits, case studies, simulated migrant/refugee patients and lived experience videos. Pre- and post-training surveys assessed practitioners’ attitudes, understanding and confidence in responding to DVA.
Twenty-three of 43 practitioners (53.5%) completed both surveys. Pre-training, 10 practitioners (43.5%) felt confident asking about violence when they thought it might be culturally accepted, and eight (34.8%) were confident locating support resources. Post-training, most practitioners (82.6%) reported increased confidence and communication skills. The training met learning needs for 19 of 23 (82.6%) participants, with 17 of 23 (73.9%) participants reporting greater understanding of cultural safety and South Asian patients’ needs. Practitioners particularly valued the advocate educator’s involvement, with 17 of 23 (73.9%) finding this ‘quite useful’ (n = 4) or ‘very useful’ (n = 13).
Although DVA training often improves knowledge and confidence, and may not change clinical behaviour or patient outcomes, embedding cultural safety in such training remains important in responding effectively to the specific needs of ethnically diverse patients and their families experiencing DVA. The HARMONY program demonstrates potential benefits of combining clinical expertise with cultural advocacy, although further research is needed to evaluate its impact on practice and patient care among other minoritised patient communities.
Keywords: cultural safety, domestic violence and abuse, general practitioners, medical education, migrant and refugee populations, primary care, professional development, training evaluation.
Introduction
Globally, one-third of women experience physical or sexual abuse by a current or former partner (Sardinha et al. 2022). Domestic violence and abuse (DVA) includes behaviour by a current/former intimate partner or close family member that is threatening, coercive, violent or abusive and causes physical, psychological, emotional, sexual or financial harm (Feder et al. 2011). The majority of DVA perpetrators are men, and victim-survivors are overwhelmingly female (Australian Institute of Health And Welfare 2018); however there are many intersecting factors, such as disability, Aboriginality, gender and sexual identity, and migration/refugee status, that can compound someone’s experience of abuse (World Health Organization 2013a).
DVA, especially intimate partner violence, is a major social, economic and gendered problem that impacts health both directly (i.e. injuries, chronic stress) and indirectly (i.e. employment or housing insecurity; Sardinha et al. 2022). DVA can have severe impacts on physical and mental health, and sexual and reproductive health (World Health Organization 2013a).
The WHO recommends healthcare providers routinely assess high-risk groups for DVA (García-Moreno et al. 2015). and be trained in first-line risk-assessment and supportive counselling of victim-survivors (Hegarty et al. 2013; García-Moreno et al. 2015). Evidence from high-income countries indicates women who experience DVA frequently attend primary care services (World Health Organization 2013b). Healthcare providers (HCPs) are often the first professional contact women may have access to, placing them in a unique position to support victim-survivors (Hegarty et al. 2013). However, GPs are hesitant to enquire about DVA, despite best-practice guidelines advocating for the identification and treatment of victim-survivors in routine health care (World Health Organization 2013b). Further to this, the compounding issues of minoritised communities add to the complexities for victim-survivors, an aspect that is lacking in some DVA models of treatment (Pokharel et al. 2021a).
Migrant/refugee victim-survivors often face additional barriers to help and health care, compounding their experiences of violence and associated harms. These can include visa uncertainty/status, fear of repercussions, a culture of shame or silence, isolation, socio-economic disadvantage, language barriers, a lack of culturally appropriate services and discrimination (Allen-Leap et al. 2022). Cultural safety in health care acknowledges historical, social and structural barriers to health care, and promotes the recognition of power imbalance, and encourages HCPs to learn from and build respectful relationships with their patients (Curtis et al. 2019).
Evidence for healthcare provider DVA training
Training healthcare providers about DVA can improve provider attitudes, knowledge and readiness to respond to female victim survivors by linking them to relevant services. There is no mandatory DVA training for HCPs, and the types, length and quality of training varies greatly. DVA training is necessary for improving HCP response, and although there is little evidence that behaviour improves, it is likely to do more good than harm. This is supported by the potential to create safer disclosure environments, increase victim-survivor access to specialised support and reduce the risk of inadvertent harm caused by inappropriate responses from untrained providers (Kalra et al. 2021).
The HARMONY study is based on a modified UK-developed GP clinic system model (IRIS; Feder et al. 2011), which successfully demonstrated that training GPs with DVA advocacy improved GP DVA recorded identification and referral. However, IRIS scholars found that an extended model to improve GPs’ support for male victims or perpetrators and/or children was not yet successful (Szilassy et al. 2021).
A recent meta-synthesis (Baloch et al. 2023), primarily including studies from South Asian countries with one UK study, investigated primary care health providers’ readiness to respond to South Asian women experiencing abuse. The analysis found many barriers that providers identified as residing with women and their culture, but also that they perceived risks to their own safety and discomfort asking all women. These findings were particularly relevant to the HARMONY study, as all participating GP clinics were required to have at least one South Asian GP. Pokharel et al. (2021b) proposed an innovative model of culturally safe DVA care in primary health care, and HARMONY incorporated this model for their South Asian patients.
HARMONY, a randomised control trial, (was derived from three world-first cluster randomised control trials identifying and responding to DVA in primary care. The overall methods for the HARMONY trial are published elsewhere (Taft et al. 2021). The three cluster randomised control trials were the IRIS study (Feder et al. 2011) described above (Feder et al. 2011); the MOSAIC trial (Taft et al. 2011), which included cultural sensitivity training, and demonstrated DVA and depression reduction among diverse women in intervention clinics; and WEAVE (Hegarty et al. 2013), an early intervention program training GPs to deliver brief supportive counselling resulting in affected women’s reduced symptoms of depression and increased GP frequency asking about the safety of women and children.
To improve health care for migrant/refugee victim-survivors, GPs require training in DVA identification and cultural safety (Curtis et al. 2019; Pokharel et al. 2021a). The HARMONY study aimed to increase DVA care through enhancing culturally safe GP identification, safety planning and referral of female victim-survivors (Taft et al. 2021). Culturally inclusive DVA curriculum and resources were developed and tested, and the multi-modal training was co-delivered by a GP specialising in DVA best practice and a bilingual DVA advocate educator. The study focused on South Asian migrant/and refugee women (Afghan, Indian, Pakistani, Bangladeshi, Sri Lankan and Nepalese), as they comprise the largest Australian migrant group with young families and are over-represented in DVA agency data (InTouch Multicultural Centre Against Family Violence 2015).
The HARMONY training integrated cultural safety into the best-practice training models trialled in these programs (Taft et al. 2021). This practice paper reports on the learnings from GPs who participated in the HARMONY culturally safe DVA training sessions.
Practice innovation
HARMONY training aimed to provide GPs and other primary health staff with the tools, knowledge and understanding to offer best-practice care and culturally safe support for their patients who were experiencing DVA. Using well established first-line response models from the WHO (World Health Organization 2021), the training addressed the staff skills, knowledge and attitudes to provide culturally safe care clinic-wide. Incorporating lived experience videos, South Asian simulated patient role-plays and a bilingual South Asian DVA advocate educator, we aimed to increase empathy and implement the principles of patient-centred, trauma-informed care. Culturally sensitive, trauma-informed GP clinics incorporating the principles of respect, privacy, confidentiality and safety enhances the likelihood of DVA disclosures (Pokharel et al. 2021a). Connecting GPs to specialised DVA bilingual/bicultural services available in the local community provides support for GPs and their DVA-affected patients (Taft et al. 2021).
Recruitment
A total of 19 GP clinics were recruited in the north-west and south-eastern regions of Melbourne, with eligibility for GP clinic participation including:
−one or more South Asian bilingual/bicultural GPs (as this increases the likelihood of South Asian patients attending these clinics)
−using Medical Director or Best Practice software (the two most commonly used clinical software systems in Australian general practice)
−agreeing to have anonymised routine DVA data extracted.
Curriculum development
The Royal Australian College of General Practitioners (RACGP) accredited, 40-point curriculum drew from previous DVA GP training (Feder et al. 2011; Taft et al. 2011; Hegarty et al. 2013; Kalra et al. 2021). Training included culturally safe clinical education resources (RACGP 2021; World Health Organization 2021). The research team developed training materials, including facilitator and participant manuals, PowerPoint presentations, access to e-learning modules, patient audits and clinic checklists. The curriculum development was heavily influenced by the culturally competent primary care DVA response model (Pokharel et al. 2021a), and collaboration between the training co-facilitators, a GP educator and a South Asian advocate educator/case manager based at InTouch Multicultural Centre Against Family Violence. Through this collaboration, the curriculum was able to provide a direct referral pathway and cultural relevancy to the participants (Pokharel et al. 2021a). Training also facilitated access to the RACGP clinical resources (The White Book) on working with migrant and refugee families experiencing violence (RACGP 2021), illustrating a national interest in this important aspect of patient care.
Training
Training was originally designed to be delivered face-to-face in two 2-h sessions. The initial sessions began in December 2019 for intervention clinics, but the trial was suspended in March 2020 due to the COVID-19 pandemic. Training was subsequently adapted to be delivered online via Zoom™ from October 2020 to May 2021 for the intervention clinics (n = 10). Comparison clinics (n = 9) served as a control group during this period, and were only offered the same training after the intervention period ended (July–August 2022).
Training materials were updated in 2020 to reflect the changed delivery method and to address DVA safety issues in telehealth use. All sessions were co-delivered by the GP educator and bilingual South Asian advocate educator/case manager, with support from research staff and a simulated South Asian patient. Online sessions were structured to build new skills, understanding and culturally competent DVA care (Pokharel et al. 2021b). See Box 1.
Box 1.HARMONY training curriculum |
Session 1 was delivered to all clinical and administrative staff as a whole-of-clinic intervention. It focused on:
|
Sessions 2 and 3 were for clinical staff only. The second session focused on:
|
The third session focused on:
|
All sessions included training on how to safely document DVA, safety planning and referrals, and the importance of accurate data entry on patient’s ethnicity and language spoken at home. |
Both the intervention and comparison GP clinics received identical instruction on how to record DVA, and were equally encouraged to increase documenting patient ethnicity and country of birth. The comparison arm was offered the training after the intervention; however, uptake was very low. Survey data from both intervention and comparison clinics were included in our analysis, although the low response rate limited our ability to conduct more complex statistical comparisons between groups.
Data collection and analysis
GPs who undertook one or more training sessions were sent pre-and post-training surveys via Redcap. Surveys included demographic information, past DVA education and adapted items from validated instruments – General Practitioners’ Perceived Readiness to identify and respond to Intimate Partner Abuse Scale (GRIPS; Leung et al. 2017) and Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS; Short et al. 2006) with cultural competency and safety questions added. The pre-training survey elicited GPs’ DVA attitudes, behaviours and current practices. The post-training survey measured GPs’ satisfaction with HARMONY training, whether learning needs were met and the usefulness of resources. Fifty-six GPs were sent the pre-training survey, and 43 the post-training survey, as they were only provided to GPs who attended one or more training sessions. Only those who completed both pre- and post-training surveys were analysed.
The data were exported, cleaned and analysed in Excel. Likert scale responses were condensed (e.g. from 6 to 4-point items – never, seldom, sometimes, nearly always, always, N/A to never/seldom, sometimes/nearly always, always, N/A) and all group proportions reported. Not applicable (N/A) or neutral responses incurred a NULL value. Univariate analysis was completed, with mean scores and response frequencies compared using descriptive statistics.
Results
GP characteristics
Twenty-eight GPs (65%) completed all three training sessions, with two (5%) completing two sessions, five (12%) completing one session – a total of 35. Eight (19%) did not attend any sessions. Training was also offered to the comparison arm and those in the intervention who missed a session; however, only two comparison clinics took this up. Twenty-three of 43 GPs (53.5%) completed pre- and post-training surveys, with 19 GPs from the intervention arm and four from the comparison arm of the trial. Of these respondents, 13 of 23 (56.5%) were male, and although most (15/23; 65.2%) GPs had previously completed some DVA training, eight of 23 (34.8%) had completed <1 h. Over half (23; 52.2%) had completed their medical education in Australia, withfive of 23 (21.7%) in a South Asian country. All three training sessions were completed by 18 of 23 (78.3%) respondents: higher (19/23; 82.6%) among the intervention group. Half completed the training online (11/23; 47.8%) or a combination of online and face-to-face (12/23; 52.2; see Table 1).
Characteristics | Mean ± s.d. | |
---|---|---|
Age (years) | 50.2 ± 11.4 | |
Years of practice in Australia | 15.9 ± 10.8 | |
Years of practice overseas | 3.7 ± 5.9 |
n (%) | ||
---|---|---|
Sex | ||
Male | 13 (56.5) | |
Female | 10 (43.5) | |
Other | 0 (0.0) | |
Previous DVA training (hours) | ||
≤1 | 8 (34.8) | |
1–5 | 8 (34.8) | |
6–15 | 4 (17.4) | |
≥16 | 3 (13.0) | |
Medical education | ||
Australia | 12 (52.2) | |
China | 3 (13.0) | |
South Asia | 5 (21.7) | |
United Kingdom | 2 (8.7) | |
Combination (multi-country) | 1 (4.3) | |
Randomisation group | ||
Intervention | 19 (82.6) | |
Comparison | 4 (17.4) | |
Completed sessions | ||
Session 1 only | 1 (4.3) | |
Session 1 and 2 | 2 (8.7) | |
Session 2 and 3 | 2 (8.7) | |
Sessions 1, 2 and 3 | 18 (78.3) | |
Participation method | ||
Face-to-face only | 1 (4.3) | |
Face-to-face and online | 11 (47.8) | |
Online only | 11 (47.8) | |
Completed E-learning module | 16 (69.6) | |
Completed patient audit | 14 (60.9) |
Cultural awareness
Pre-training, GPs were surveyed about their DVA clinical practice with patients from different countries, religions or cultures, and their perception of other cultures’ attitudes and acceptance of DVA. Although 73.9% of GPs supported asking about DVA regardless of a patient’s country of birth, religion or culture, less than half (43.5%) were confident asking about DVA, if they thought it could be accepted as part of a patient’s religion or culture (see Table 2). In the post-training survey, 73.9% of GPs reported they had a greater understanding of cultural safety and the needs of South Asian DVA patients. All participants identified that it was relevant to learn about working with South Asian women experiencing DVA, with most participants (73.9%) reporting that the advocate/educator was either ‘quite or very useful’ (see Table 3).
Thinking about patient care you have provided in the last 3 months; how comfortable did you feel asking about the following? | Never asked n (%) | Uncomfortable n (%) | Comfortable n (%) | Null n (%) | |
---|---|---|---|---|---|
General anxiety | 0 (0.0) | 1 (4.3) | 21 (95.7) | 0 (0.0) | |
Depression | 0 (0.0) | 1 (4.3) | 21 (95.7) | 0 (0.0) | |
Relationship problems | 0 (0.0) | 4 (17.4) | 19 (82.6) | 0 (0.0) | |
Social isolation | 1 (4.3) | 3 (13.0) | 19 (82.6) | 0 (0.0) | |
Past sexual abuse | 1 (4.3) | 10 (43.5) | 12 (52.2) | 0 (0.0) | |
Family violence | 1 (4.3) | 11 (47.8) | 11 (47.8) | 0 (0.0) |
Please complete the following section in relation to your views on family violence (DVA) in your role at the clinic. How much do you agree with the following statements? | Disagree | Neither agree nor disagree | Agree | Null | |
---|---|---|---|---|---|
I feel that it is important to ask about DVA among my patients, regardless of country, cultural or religious background | 1 (4.3) | 4 (17.4) | 17 (73.9) | 1 (4.3) | |
I feel comfortable asking patients who I have known for some time about DVA | 3 (13.0) | 5 (21.7) | 13 (56.5) | 2 (8.7) | |
I feel confident asking about DVA even though it might be an accepted part of my patients’ religion or culture | 5 (21.7) | 8 (34.8) | 10 (43.5) | 0 (0.0) | |
I feel confident identifying patients’ needs when they experience DVA | 7 (30.4) | 7 (30.4) | 9 (39.1) | 0 (0.0) | |
I feel confident addressing DVA victims’ concerns about their children’s safety | 9 (39.1) | 5 (21.7) | 9 (39.1) | 0 (0.0) | |
I am confident that I can locate resources (such as community agencies, referral resources) for patients who experience DVA | 9 (39.1) | 6 (26.1) | 8 (34.8) | 0 (0.0) | |
I do not have adequate knowledge of DVA issues to help patients being abused | 5 (21.7) | 9 (39.1) | 7 (30.4) | 2 (8.7) | |
I have adequate counselling skills to support DVA victims | 13 (56.5) | 5 (21.7) | 5 (21.7) | 0 (0.0) | |
When I suspect that my patient is experiencing DVA, I know what appropriate questions to ask | 5 (21.7) | 13 (56.5) | 5 (21.7) | 0 (0.0) | |
I am able to recognise different kinds of clinical presentations of DVA | 6 (26.1) | 10 (43.5) | 5 (21.7) | 2 (8.7) | |
I feel confident assessing whether my patients are safe to go home in an abusive situation | 13 (56.5) | 6 (26.1) | 4 (17.4) | 0 (0.0) |
How often in the past 3 months have you asked about the possibility of family violence when seeing female patients with the following | Never/seldom | Sometimes | Always | Null/N/A | |
---|---|---|---|---|---|
Depression/anxiety/suicidal intentions | 5 (21.7) | 10 (43.5) | 7 (30.4) | 1 (4.3) | |
Chronic pain | 11 (47.8) | 8 (34.8) | 4 (17.4) | 0 (0.0) | |
Eating disorder | 9 (39.1) | 7 (30.4) | 3 (13.0) | 4 (17.4) | |
Injuries | 11 (47.8) | 6 (26.1) | 2 (8.7) | 4 (17.4) | |
Chronic pelvic pain | 13 (56.5) | 6 (26.1) | 1 (4.3) | 3 (13.0) | |
Irritable bowel syndrome | 18 (78.3) | 3 (13.0) | 1 (4.3) | 1 (4.3) | |
Headaches | 16 (69.6) | 6 (26.1) | 1 (4.3) | 0 (0.0) |
Please rate the following aspects of the HARMONY training program regarding the sessions you did attend (if any) | Poor n (%) | Good n (%) | Excellent n (%) | Null/N/A n (%) | |
---|---|---|---|---|---|
Overall quality of the program as a learning experience | 0 (0.0) | 5 (21.7) | 18 (78.3) | 0 (0.0) | |
Learning gained in session 1 | 0 (0.0) | 6 (26.1) | 15 (65.2) | 2 (8.7) | |
Learning gained in session 2 | 0 (0.0) | 5 (21.7) | 17 (73.9) | 1 (4.3) | |
Learning gained in session 3 | 0 (0.0) | 4 (17.4) | 16 (69.6) | 3 (13.0) | |
Learning gained in follow-up with InTouch advocate educator (case manager) | 1 (4.3) | 6 (26.1) | 10 (43.5) | 6 (26.1) | |
Relevance of learning to working with South-Asian women experiencing family violence | 0 (0.0) | 7 (30.4) | 15 (65.2) | 1 (4.3) | |
Opportunity to ask questions about family violence | 0 (0.0) | 5 (21.7) | 16 (69.6) | 2 (8.7) | |
Opportunity to ask questions about cultural competency | 2 (8.7) | 7 (30.4) | 13 (56.5) | 1 (4.3) | |
Opportunity to interact with other participants | 2 (8.7) | 9 (39.1) | 11 (47.8) | 1 (4.3) | |
Relevance of learning how to safely document family violence in patient records and refer to inTouch | 1 (4.3) | 7 (30.4) | 14 (60.9) | 1 (4.3) | |
Appropriateness of the length of the training program and amount of material covered | 0 (0.0) | 7 (30.4) | 15 (65.2) | 1 (4.3) |
Please rate whether the following met your learning needs | Not at all met | Partially met | Completely met | Null/N/A | |
---|---|---|---|---|---|
Opportunity to improve communication skills, including active listening and responding to patients experiencing family violence | 0 (0.0) | 3 (13.0) | 19 (82.6) | 1 (4.3) | |
Increased confidence in ability to talk to patients about family violence | 0 (0.0) | 3 (13.0) | 19 (82.6) | 1 (4.3) | |
Increased understanding of the point of view of patients experiencing family violence | 0 (0.0) | 3 (13.0) | 19 (82.6) | 1 (4.3) | |
Improved ability to support patients experiencing family violence | 0 (0.0) | 3 (13.0) | 19 (82.6) | 1 (4.3) | |
Improved understanding of how to respond appropriately to the needs of South-Asian patients experiencing family violence | 0 (0.0) | 5 (21.7) | 17 (73.9) | 1 (4.3) | |
Developed skills to assess a family violence patient’s readiness for change | 0 (0.0) | 3 (13.0) | 18 (78.3) | 2 (8.7) | |
Improved understanding of trauma informed care | 0 (0.0) | 3 (13.0) | 18 (78.3) | 2 (8.7) | |
Greater understanding of the importance of culturally competent family violence support | 0 (0.0) | 5 (21.7) | 17 (73.9) | 1 (4.3) | |
Developed skills to assess the safety of patients and children | 0 (0.0) | 5 (21.7) | 16 (69.6) | 2 (8.7) | |
Enabled me to access recent evidence regarding family violence | 0 (0.0) | 5 (21.7) | 17 (73.9) | 1 (4.3) | |
Ability to reflect on my own attitudes towards family violence | 0 (0.0) | 3 (13.0) | 19 (82.6) | 1 (4.3) | |
Overall, the degree to which your learning needs were met | 0 (0.0) | 4 (17.4) | 19 (82.6) | 0 (0.0) |
This section asks you for feedback about the resources provided to you and how useful they were to you | Not useful | Quite useful | Very useful | Null/N/A | |
---|---|---|---|---|---|
Participant handbook | 3 (13.0) | 12 (52.2) | 8 (34.8) | 0 (0.0) | |
Cultural competency resources included in the Participant Handbook | 5 (21.7) | 10 (43.5) | 8 (34.8) | 0 (0.0) | |
The RACGP white book | 9 (39.1) | 7 (30.4) | 6 (26.1) | 1 (4.3) | |
UniMelb e-Learning module on domestic violence | 4 (17.4) | 6 (26.1) | 12 (52.2) | 1 (4.3) | |
HealthPathways | 8 (34.8) | 6 (26.1) | 8 (34.8) | 1 (4.3) | |
inTouch advocate educator (case manager) in the training, and as a source of support and information | 5 (21.7) | 4 (17.4) | 13 (56.5) | 1 (4.3) | |
Other referral resources | 8 (34.8) | 6 (26.1) | 8 (34.8) | 1 (4.3) |
Overall, please rate | Not relevant | Partially relevant | Entirely relevant | Null/NA | |
---|---|---|---|---|---|
The extent to which this training is relevant to your practice | 1 (4.3) | 4 (17.4) | 18 (78.3) | 0 (0.0) |
Culturally safe responses to DVA
Prior to training, many GPs did not feel able to address DVA victims’ safety concerns at home (56.5%), and only 39.1% felt confident in addressing concerns about the safety of DVA victims’ children. Only one-third (34.8%) of GPs were confident they could locate resources, such as community agencies and DVA referral services (see Table 2). Post-training, 69.6% of GPs reported they developed better skills to assess the safety of patients, including children. GPs reported the relevance of learning to work with a South Asian DVA victim was either ‘good’ (30.4%) or ‘excellent’ (65.2%), and a further 91.4% reported either ‘good’ or ‘excellent’ on learning how to safely document DVA patient records and refer to the culturally safe DVA service, inTouch. Most GPs (78.3%) reported training completely met their needs to develop skills to assess DVA patients, and it improved their understanding of trauma-informed DVA care. Most GPs (82.6%) identified improvement in their ability to support DVA patients (see Table 3).
Building confidence, clinical skills and communication
Pre-training, GPs did not believe they had adequate counselling skills to support DVA patients (21.7%), and felt most comfortable asking about depression (95.7%), and least comfortable asking about DVA (47.8%). GPs sometimes (43.5%) or always (30.4%) asked about DVA when a female patient presented with depression, anxiety or suicidal intentions. Over half of the GPs (56.5%) neither agreed nor disagreed that they knew the appropriate questions to ask when they suspected DVA. GPs’ ability to recognise different clinical presentations of DVA was low at 21.7%, with many seldom asking about DVA when patients presented with injuries (47.8%), headaches (69.6%) or irritable bowel syndrome (78.3%; see Table 2). Post-training, 82.6% of GPs reported an improvement in their communication skills, and increased confidence and understanding of DVA.
Additionally, 82.6% reported an increase in understanding the patients’ point of view regarding DVA, and 78.3% developed skills assessing DVA patients’ readiness to change. The post-training survey identified that overall, the training met the learning needs of the great majority of GPs (82.6%) and was relevant to their practice (78.3%; see Table 3).
Learnings from HARMONY
The HARMONY training addressed the knowledge gap in GP education on culturally safe best-practices when identifying and supporting DVA patients. This practice paper highlights that GPs educated in culturally safe DVA care can increase confidence and clinical skills in addressing the needs of migrant/and refugee women experiencing DVA. Given the increased risks of serious harm or death, and the many compounding factors faced by migrant/and refugee women experiencing DVA, particularly during the COVID-19 pandemic (InTouch Multicultural Centre Against Family Violence 2015; Kourti et al. 2021), embedding cultural safety into GP DVA training is essential (Pokharel et al. 2021a). Although other healthcare provider DVA training has demonstrated an increase in provider knowledge and confidence that supports greater willingness to enquire about and identify DVA (Hegarty et al. 2020; Tarzia et al. 2021), previous training programs have not included cultural safety elements (Pokharel et al. 2021a). It is important to note, however, that although HCP training often improves knowledge and attitudes, there is a lack of evidence for behaviour change or patient outcomes (Zaher et al. 2014; Kalra et al. 2021). There is also the matter of self-selection bias, as HCPS are drawn to courses/education in which they already have an interest (Kusurkar et al. 2011).
Integrating a DVA advocate educator/case manager into GP training with follow-up support was successfully trialled in the UK (Feder et al. 2011). Providing a bicultural/bilingual DVA advocate educator/case manager combined with a GP educator has ensured clinical skills and cultural competency were both at the forefront of the HARMONY training. The incorporation of culturally sensitive multi-modal and interactive training, such as role-play with a simulated South Asian DVA patient, allowed GPs a chance to develop their skills and reflect on their practice (Pokharel et al. 2021a), which supports other research recommending experiential approaches to training (Kalra et al. 2021).
Our findings that GPs lack confidence in completing safety plans, risk assessments and struggle to recognise different presentations of DVA are not unusual (Hegarty et al. 2020). Limited GP knowledge of DVA-specific resources was not uncommon compared with other studies of healthcare provider readiness to support DVA patients (García-Moreno et al. 2015; Hegarty et al. 2020; Kalra et al. 2021). HARMONY training, like other healthcare providers’ DVA training (O’Doherty et al. 2015), increased GPs’ reported confidence and communication skills, including active listening and appropriate responses to patients experiencing DVA (World Health Organization 2021). Most healthcare providers consistently indicate they want to support victim-survivors, but their confidence and preparedness to undertake DVA work varies (Hegarty et al. 2020). This was often impacted by the level of training, time commitment and understanding of how they can support their DVA patients within the current health and social-welfare system (Ghafournia 2011; García-Moreno et al. 2015; Hegarty et al. 2020; Tarzia et al. 2021). This highlights the importance of systems-level support (García-Moreno et al. 2015), addressing GPs’ and patients’ readiness to change (Hegarty et al. 2013), trauma-informed care (Ponic et al. 2016), as well as mnemonic learning aids, such as the LIVES (World Health Organization 2021) and CARE models (Tarzia et al. 2020), in training to ensure a victim-centred and culturally safe response by GPs (Pokharel et al. 2021a).
Strengths and limitations
This practice paper provides insight into culturally safe DVA training. Despite the impact of COVID-19, the training was delivered successfully online, and met the GPs’ learning needs and expectations. There are some limitations in the use of self-reported data and the low response rate, which have potential validity issues; however, they are a useful measure of participant confidence and perspective on skill development and attitudes. An additional limitation was the difference in pre- and post-survey questions, which prevented direct statistical comparisons. The research is limited by the available sample size and the descriptive nature of the analysis; however, the trial outcomes and process evaluation papers will describe changes in GPs’ actual recorded practice.
Recommendations for future practice
Improvements in DVA clinical skills require GPs to undertake regular and ongoing comprehensive training with follow-up support, such as a DVA case worker. To ensure GPs are culturally safe, in areas with significant migrant/refugee populations, joint training by a GP educator and bilingual DVA advocate, enabling better engagement with an advocate educator/case manager from a migrant/refugee specialist service might be helpful.
Conclusion
The HARMONY training responded to a significant need for GP DVA training with cultural safety embedded. The training is relevant to primary care services in high-income countries with large diaspora populations, so services can support GPs to respond safely to culturally diverse population needs.
Data availability
The data supporting this study cannot be publicly shared due to ethical or privacy reasons, but it may be shared upon reasonable request to the corresponding author if appropriate.
Declaration of funding
The HARMONY Study was funded by NHMRC Partnerships in Health fund, Commonwealth of Australia Department of Social Services, Victorian Government Department of Multicultural Affairs and Social Inclusion.
Acknowledgements
The authors acknowledge the co-facilitators of the HARMONY training, Dr Jennifer Neil, Monash University, and Asha Padisetti, inTouch Multicultural Centre Against Family Violence, for their significant contribution to the delivery of the program.
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