The HARMONY trial: assessing general practitioner knowledge, attitudes and confidence following culturally safe domestic violence and abuse training

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.

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.

Ethics

Ethical approval was received from La Trobe University Human Ethics Committee Application (HEC18413).

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).

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).

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.