Identification And Referral To Improve Safety Research Articles

Feasibility of a reconfigured domestic violence and abuse training and support intervention responding to affected women, men, children and young people through primary care

BackgroundIdentification in UK general practice of women affected by domestic violence and abuse (DVA) is increasing, but men and children/young people (CYP) are rarely identified and referred for specialist support. To address this gap, we collaborated with IRISi (UK social enterprise) to strengthen elements of the IRIS + intervention which included the identification of men, direct engagement with CYP, and improved guidance on responding to information received from other agencies. IRIS + was an adaptation of the national IRIS (Identification and Referral to Improve Safety) model focused on the needs of women victim-survivors of DVA. Without diminishing the responses to women, IRIS + also responded to the needs of men experiencing or perpetrating DVA, and CYP living with DVA and/or experiencing it in their own relationships. Our study tested the feasibility of the adapted IRIS + intervention in England and Wales between 2019–21.MethodsWe used mixed method analysis to triangulate data from various sources (pre/post intervention questionnaires with primary care clinicians; data extracted from medical records and DVA agencies; semi-structured interviews with clinicians, service providers and referred adults and children) to assess the feasibility and acceptability of the IRIS + intervention.ResultsThe rate of referral for women doubled (21.6/year/practice) from the rate (9.29/year/practice) in the original IRIS trial. The intervention also enabled identification and direct referral of CYP (15% of total referrals) and men (mostly survivors, 10% of total referrals). Despite an increase in self-reported clinician preparedness to respond to all patient groups, the intervention generated a low number of men perpetrator referrals (2% of all referrals). GPs were the principal patient referrers. Over two-thirds of referred women and CYP and almost half of all referred men were directly supported by the service. Many CYP also received IRIS + support indirectly, via the referred parents. Men and CYP supported by IRIS + reported improved physical and mental health, wellbeing, and confidence.ConclusionsAlthough the study showed acceptability and feasibility, there remains uncertainty about the effectiveness, cost-effectiveness, and scalability of IRIS + . Building on the success of this feasibility study, the next step should be trialling the effectiveness of IRIS + implementation to inform service implementation decisions.

COVID-19 adaptations to a training and support programme to improve primary care response to domestic abuse: a mixed methods rapid study

BackgroundIncreased incidence and/or reporting of domestic abuse (DA) accompanied the COVID-19 pandemic. National lockdowns and enforced social isolation necessitated new ways of supporting victims of DA remotely. Identification and Referral to Improve Safety (IRIS) is a programme to improve the response to domestic abuse in general practice, providing training for general practice teams and support for patients affected by DA, which has previously been proven effective and cost-effective [1–3]. The COVID-19 pandemic required the adaptation of the programme to online training and remote support.MethodsThis study is mixed methods rapid research, which aimed to gather evidence around the relevance, desirability and acceptability of IRIS operating remotely. Quantitative IRIS referral data were triangulated with data from four surveys and 15 interviews. Participants were local IRIS teams, IRIS-trained clinicians, and victim-survivors supported by IRIS services. The study was designed using the Lean Impact approach, allowing quick evaluation of innovation and the impact of social interventions. We carried out a framework analysis of the interviews, which is a qualitative methodology widely used in policy and applied research that enables research teams to move from descriptive accounts to a conceptual explanation of findings [4, 5].ResultsWe found that the adaptation to online training and support of IRIS was acceptable and desirable. Most clinicians felt confident addressing DA over the phone and online, although most were more confident face-to-face. While referrals to IRIS services initially declined in March 2020, numbers of referrals increased to pre-pandemic levels by July 2020. Patients felt well supported remotely, although patients who had previously experienced face-to-face support preferred it. Technology was the most frequently mentioned barrier to the change from face-to-face training and support to online training and remote support.ConclusionsThis study contributes to practice by asserting the desirability and acceptability of training clinicians to be able to identify, ask about DA and refer to the IRIS programme during telephone/online consultations. This is of relevance to health and public health commissioners when making commissioning decisions to improve the general practice response to domestic abuse.

Adapting domestic abuse training to remote delivery during the COVID-19 pandemic: a qualitative study of views from general practice and support services.

Identifying and responding to patients affected by domestic violence and abuse (DVA) is vital in primary care. There may have been a rise in the reporting of DVA cases during the COVID-19 pandemic and associated lockdown measures. Concurrently general practice adopted remote working that extended to training and education. IRIS (Identification and Referral to Improve Safety) is an example of an evidence-based UK healthcare training support and referral programme, focusing on DVA. IRIS transitioned to remote delivery during the pandemic. To understand the adaptations and impact of remote DVA training in IRIS-trained general practices by exploring perspectives of those delivering and receiving training. Qualitative interviews and observation of remote training of general practice teams in England were undertaken. Semi-structured interviews were conducted with 21 participants (three practice managers, three reception and administrative staff, eight general practice clinicians, and seven specialist DVA staff), alongside observation of eight remote training sessions. Analysis was conducted using a framework approach. Remote DVA training in UK general practice widened access to learners. However, it may have reduced learner engagement compared with face-to-face training and may challenge safeguarding of remote learners who are domestic abuse survivors. DVA training is integral to the partnership between general practice and specialist DVA services, and reduced engagement risks weakening this partnership. The authors recommend a hybrid DVA training model for general practice, including remote information delivery alongside a structured face-to-face element. This has broader relevance for other specialist services providing training and education in primary care.

General practice wide adaptations to support patients affected by DVA during the COVID-19 pandemic: a rapid qualitative study

BackgroundReporting of domestic violence and abuse (DVA) increased globally during the pandemic. General Practice has a central role in identifying and supporting those affected by DVA. Pandemic associated changes in UK primary care included remote initial contacts with primary care and predominantly remote consulting. This paper explores general practice’s adaptation to DVA care during the COVID-19 pandemic.MethodsRemote semi-structured interviews were conducted by telephone with staff from six localities in England and Wales where the Identification and Referral to Improve Safety (IRIS) primary care DVA programme is commissioned. We conducted interviews between April 2021 and February 2022 with three practice managers, three reception and administrative staff, eight general practice clinicians and seven specialist DVA staff. Patient and public involvement and engagement (PPI&E) advisers with lived experience of DVA guided the project. Together we developed recommendations for primary care teams based on our findings.ResultsWe present our findings within four themes, representing primary care adaptations in delivering DVA care: 1. Making general practice accessible for DVA care: staff adapted telephone triaging processes for appointments and promoted availability of DVA support online. 2. General practice team-working to identify DVA: practices developed new approaches of collaboration, including whole team adaptations to information processing and communication 3. Adapting to remote consultations about DVA: teams were required to adapt to challenges including concerns about safety, privacy, and developing trust remotely. 4. Experiences of onward referrals for specialist DVA support: support from specialist services was effective and largely unchanged during the pandemic.ConclusionsDisruption caused by pandemic restrictions revealed how team dynamics and interactions before, during and after clinical consultations contribute to identifying and supporting patients experiencing DVA. Remote assessment complicates access to and delivery of DVA care. This has implications for all primary and secondary care settings, within the NHS and internationally, which are vital to consider in both practice and policy.

Impacts of an Intervention to Improve the Identification, Referral and Safety of Those Experiencing Domestic Violence: A Mixed Methods Study in the UK

This study is the first evaluation of the impacts on long-term health issues (and associations with ethnicity and poverty) of a domestic violence intervention, Identification and Referral to Improve Safety (IRIS). IRIS is a domestic violence training, support and referral programme based mainly in primary care settings. This was a convergent, parallel, mixed methods UK study. In the quantitative phase, we matched the health records of 294 patients who had a marker for domestic violence with records from a domestic violence support service to track the health conditions of participants before and after referral to IRIS. In the qualitative phase, we conducted semi-structured telephone interviews with 21 women who had received IRIS support and thematically analysed the data. Descriptive statistics indicated that, at the point of referral to IRIS, participants had a variety of health conditions, with a reduction on a number of mental and overall physical health conditions post-IRIS. Qualitative data are reported under five prominent themes: life before, driving forces for help-seeking, experiences of support, perceived impacts and recovery as a journey. Overall, we found that IRIS support was associated with a positive impact on participants. The study highlights the benefits of improved identification and referral of domestic violence survivors.

Impact of the first national COVID-19 lockdown on referral of women experiencing domestic violence and abuse in England and Wales

BackgroundThe lockdown periods to curb COVID-19 transmission have made it harder for survivors of domestic violence and abuse (DVA) to disclose abuse and access support services. Our study describes the impact of the first COVID-19 wave and the associated national lockdown in England and Wales on the referrals from general practice to the Identification and Referral to Improve Safety (IRIS) DVA programme. We compare this to the change in referrals in the same months in the previous year, during the school holidays in the 3 years preceding the pandemic and the period just after the first COVID-19 wave. School holiday periods were chosen as a comparator, since families, including the perpetrator, are together, affecting access to services.MethodsWe used anonymised data on daily referrals received by the IRIS DVA service in 33 areas from general practices over the period April 2017–September 2020. Interrupted-time series and non-linear regression were used to quantify the impact of the first national lockdown in March–June 2020 comparing analogous months the year before, and the impact of school holidays (01/04/2017–30/09/2020) on number of referrals, reporting Incidence Rate Ratio (IRR), 95% confidence intervals and p-values.ResultsThe first national lockdown in 2020 led to reduced number of referrals to DVA services (27%, 95%CI = (21,34%)) compared to the period before and after, and 19% fewer referrals compared to the same period in the year before. A reduction in the number of referrals was also evident during the school holidays with the highest reduction in referrals during the winter 2019 pre-pandemic school holiday (44%, 95%CI = (32,54%)) followed by the effect from the summer of 2020 school holidays (20%, 95%CI = (10,30%)). There was also a smaller reduction (13–15%) in referrals during the longer summer holidays 2017–2019; and some reduction (5–16%) during the shorter spring holidays 2017–2019.ConclusionsWe show that the COVID-19 lockdown in 2020 led to decline in referrals to DVA services. Our findings suggest an association between decline in referrals to DVA services for women experiencing DVA and prolonged periods of systemic closure proxied here by both the first COVID-19 national lockdown or school holidays. This highlights the need for future planning to provide adequate access and support for people experiencing DVA during future national lockdowns and during the school holidays.

The Identification and Referral to Improve Safety Programme and the Prevention of Intimate Partner Violence.

Introduction: Intimate Partner Violence (IPV) is a global epidemic which 30% of women experience world-wide. Domestic violence has serious health consequences, with an estimated cost of 1.7 billion annually to the NHS. However, healthcare professionals remain uncertain on how to manage IPV. In 2007, the Identification and Referral to Improve Safety (IRIS) was introduced within primary care to address this shortcoming. The aim of this project is to analyse the impact of IRIS, whilst discussing the extension into secondary care. Materials and Methods: A literature review was conducted using PubMed, Cochrane Library and Google scholar. The official IRIS publication list for randomized controlled trial data. Results: General practices with IRIS displayed a threefold increase in the identification of IPV and sevenfold increase in referrals. IRIS is cost-effective and under the NICE threshold of £20,000 per quality-adjusted life year gained. Additionally, a systematic review illustrated that one in six women presenting to the fracture clinic experienced IPV within the last year. Conclusions: The implementation of IRIS into general practice proved to be cost-effective. Orthopaedic fracture clinics are at the forefront of dealing with IPV, and therefore an adapted IRIS programme within this setting has potential in the prevention of IPV.

PRimary care rEsponse to domestic violence and abuse in the COvid-19 panDEmic (PRECODE): protocol of a rapid mixed-methods study in the UK

BackgroundThe implementation of lockdowns in the UK during the COVID-19 pandemic resulted in a system switch to remote primary care consulting at the same time as the incidence of domestic violence and abuse (DVA) increased. Lockdown-specific barriers to disclosure of DVA reduced the opportunity for DVA detection and referral.The PRECODE (PRimary care rEsponse to domestic violence and abuse in the COvid-19 panDEmic) study will comprise quantitative analysis of the impact of the pandemic on referrals from IRIS (Identification and Referral to Improve Safety) trained general practices to DVA agencies in the UK and qualitative analysis of the experiences of clinicians responding to patients affected by DVA and adaptations they have made transitioning to remote DVA training and patient support.Methods/DesignUsing a rapid mixed method design, PRECODE will explore and explain the dynamics of DVA referrals and support before and during the pandemic on a national scale using qualitative data and over four years of referrals time series data.We will undertake interrupted-time series and non-linear regression analysis, including sensitivity analyses, on time series of referrals to DVA services from routinely collected data to evaluate the impact of the pandemic and associated lockdowns on referrals to the IRIS Programme, and analyse key determinants associated with changes in referrals.We will also conduct an interview- and observation-based qualitative study to understand the variation, relevance and feasibility of primary care responses to DVA before and during the pandemic and its aftermath.The triangulation of quantitative and qualitative findings using rapid analysis and synthesis will enable the articulation of multiscale trends in primary care responses to DVA and complex mechanisms by which these responses have changed during the pandemic.DiscussionOur findings will inform the implementation of remote primary care and DVA service responses as services re-configure. Understanding the adaptation of clinical and service responses to DVA during the pandemic is crucial for the development of evidence-based, effective remote support and referral beyond the pandemic.Trial registrationPRECODE is an observational epidemiologic study, not an intervention evaluation or trial. We will not be reporting results of an intervention on human participants.

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

BackgroundPrimary 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.MethodsObservation 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.ResultsClinicians 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.ConclusionsThe 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.

Specialist support for survivors of domestic abuse during COVID-19

Health visitors have a crucial and unique role in identifying and supporting those affected by domestic abuse as the current pandemic increases the risk of harm towards survivors. This article reflects on how COVID-19 and lockdown restrictions have exacerbated risks to survivors, barriers to support and the mental and physical health effects. It will provide insight into how frontline domestic abuse workers at Solace Women's Aid have continued to support survivors, from the experience of three Identification and Referral to Improve Safety (IRIS) Advocate Educators, working across two London boroughs.

Disruption of a primary health care domestic violence and abuse service in two London boroughs: interrupted time series evaluation

BackgroundDomestic violence and abuse (DVA) is experienced by about 1/3 of women globally and remains a major health concern worldwide. IRIS (Identification and Referral to Improve Safety of women affected by DVA) is a complex, system-level, training and support programme, designed to improve the primary healthcare response to DVA. Following a successful trial in England, since 2011 IRIS has been implemented in eleven London boroughs. In two boroughs the service was disrupted temporarily. This study evaluates the impact of that service disruption.MethodsWe used anonymised data on daily referrals received by DVA service providers from general practices in two IRIS implementation boroughs that had service disruption for a period of time (six and three months). In line with previous work we refer to these as boroughs B and C. The primary outcome was the number of daily referrals received by the DVA service provider across each borough over 48 months (March 2013–April 2017) in borough B and 42 months (October 2013–April 2017) in borough C. The data were analysed using interrupted-time series, non-linear regression with sensitivity analyses exploring different regression models. Incidence Rate Ratio (IRR), 95% confidence intervals and p-values associated with the disruption were reported for each borough.ResultsA mixed-effects negative binomial regression was the best fit model to the data. In borough B, the disruption, lasted for about six months, reducing the referral rate significantly (p = 0.006) by about 70% (95%CI = (23,87%)). In borough C, the three-month service disruption, also significantly (p = 0.005), reduced the referral rate by about 49% (95% CI = (18,68%)).ConclusionsDisrupting the IRIS service substantially reduced the rate of referrals to DVA service providers. Our findings are evidence in favour of continuous funding and staffing of IRIS as a system level programme.

Exploring primary care responses to domestic violence and abuse (DVA): operationalisation of a national initiative

PurposeIn the UK, the Identification and Referral to Improve Safety (IRIS) initiative has been developed for use within primary care to support women survivors of domestic violence and abuse (DVA). However, while evaluated nationally, less is known regarding impact of implementation at a local level. The purpose of this paper is to explore the effectiveness of IRIS within one locality in the UK.Design/methodology/approachA qualitative study using interviews/focus groups with primary care teams and women who had experienced DVA in one primary care setting in the UK. Interviews with 18 participants from five professional categories including: general practitioners, practice nurses, practice managers, assistant practice managers and practice receptionists. Focus group discussion/interview with seven women who had accessed IRIS. Data were collected between November 2016 and March 2017.FindingsFive main themes were identified for professionals: Team role approach to training, Professional confidence, Clear pathway for referral and support, Focussed support, Somewhere to meet that is a “safe haven”. For women the following themes were identified: Longevity of DVA; Lifeline; Face to face talking to someone; Support and understood where I was coming from; A place of safety.Practical implicationsIRIS played a significant role in helping primary care professionals to respond effectively. For women IRIS was more proactive and holistic than traditional approaches.Originality/valueThis study was designed to assess the impact that a local level implementation of the national IRIS initiative had on both providers and users of the service simultaneously. The study identifies that a “whole team approach” in the primary care setting is critical to the effectiveness of DVA initiatives.

Implementation of the Identification and Referral to Improve Safety programme for patients with experience of domestic violence and abuse: A theory-based mixed-method process evaluation.

Identification and Referral to Improve Safety (IRIS) is a training and support programme to improve the response to domestic violence and abuse (DVA) in general practice. Following a pragmatic cluster‐randomised trial, IRIS has been implemented in over 30 administrative localities in the UK. The trial and local evaluations of the IRIS implementation showed an increase in referrals from general practice to third sector DVA services with a variation in the referral rates within and across practices. Using Normalisation Process Theory (NPT), we aimed to understand the reasons for such variability by identifying factors that influenced the implementation of IRIS in the National Health Service (NHS). We conducted a mixed‐method process evaluation which included: (a) a case study (100 hr of participant observation, 19 interviews); (b) a survey (n = 118); (c) qualitative analysis of free‐text comments from the survey; (d) qualitative interviews (n = 8); (e) document review (n = 44). Data were collected from NHS and third sector staff across five London boroughs from August 2015 to December 2017, analysed descriptively and thematically and triangulated using the NPT constructs coherence, cognitive participation, collection action and reflexive monitoring. The survey showed wide variation in the extent to which practice staff saw IRIS as a normal part of their daily work. Qualitative data and documents illuminated drivers of DVA work, implementation barriers and suggested solutions. The drivers were related to individual professional's characteristics and relationships. The barriers were linked to the differing sense‐making and legitimisation of DVA work and differing contexts between the NHS and third sector. Solutions were adaptations to IRIS relative to these contextual differences. The suggested solutions can be used to update IRIS commissioning guidance, training for trainers and training for general practice. The updates should reflect the importance of ongoing support of IRIS from practice leads and commissioners, extended funding periods for IRIS and continuity of the IRIS team.

Improving the healthcare response to domestic violence and abuse in primary care: protocol for a mixed method evaluation of the implementation of a complex intervention

BackgroundDomestic violence and abuse remains a major health concern. It is unknown whether the improved healthcare response to domestic violence and abuse demonstrated in a cluster randomised controlled trial of IRIS (Identification and Referral to Improve Safety), a complex intervention, including general practice based training, support and referral programme, can be achieved outside a trial setting. Aim: To evaluate the impact over four years of a system wide implementation of IRIS, sequentially into multiple areas, outside the setting of a trial.MethodsAn interrupted time series analysis of referrals received by domestic violence and abuse workers from 201 general practices, in five northeast London boroughs; alongside a mixed methods process evaluation and qualitative analysis. Segmented regression interrupted time series analysis to estimate impact of the IRIS intervention over a 53-month period. A secondary analysis compares the segmented regression analysis in each of the four implementation boroughs, with a fifth comparator borough.DiscussionThis is the first interrupted time series analysis of an intervention to improve the health care response to domestic violence. The findings will characterise the impact of IRIS implementation outside a trial setting and its suitability for national implementation in the United Kingdom.

Cost-effectiveness of a domestic violence and abuse training and support programme in primary care in the real world: updated modelling based on an MRC phase IV observational pragmatic implementation study

ObjectivesTo evaluate the cost-effectiveness of the implementation of the Identification and Referral to Improve Safety (IRIS) programme using up-to-date real-world information on costs and effectiveness from routine clinical practice. A...

Assessing for domestic violence in sexual health environments: a qualitative study

ObjectivesDomestic violence and abuse (DVA) is a major clinical challenge and public health issue. Sexual health services are an important potential site of DVA intervention. The Assessing for Domestic Violence...

Reducing symbolic-violence in the research encounter: collaborating with a survivor of domestic abuse in a qualitative study in UK primary care.

This paper explores ideas of symbolic violence inherent in the research encounter (Bourdieu 1999). After defining symbolic violence and how the concept enters into domestic violence and abuse (DVA) research, we discuss the challenges arising from a (DVA) survivor taking on the role of interviewer in a qualitative study nested within a UK primary care based trial: IRIS (Identification and Referral to Improve Safety). KS, a survivor of DVA, conducted interviews with 12 women who had been referred to a domestic violence agency by primary care clinicians taking part in the IRIS trial in two UK cities (Bristol and east London) during 2009. Field notes were kept during all of the research meetings with KS and these were included in analysis. Our analysis maps the research pathway of 'non-violent communication' and discusses the role of social symmetry and proximity in the research encounter. We conclude that while a welcoming disposition, empathy and active listening are all generic skills to qualitative research; if a researcher can enter fieldwork with a claim of social proximity and symmetry, their use of these generic skills is enhanced through a process of shared objectification and empowerment talk. We explore the limitations of social proximity, its relationship to feminist and anthropological theories of 'insider' research and its relevance to primary care research.

O13 Iris advise: assessing for domestic violence in sexual health environments (a pilot study)

<h3>Background/introduction</h3> Sexual health and gynaecological problems are the most consistent and largest physical health differences between abused and non-abused populations. Sexual health services are well placed to identify and support people experiencing domestic violence and abuse (DVA). Most sexual health professionals have no DVA training despite NICE recommendations. IRIS (Identification and Referral to Improve Safety) is a national GP training intervention that improved the primary-care response to DVA. <h3>Aim(s)/objectives</h3> To pilot an IRIS-based training intervention on assessing for domestic violence in sexual health environments (ADViSE), and evaluate its feasibility and effectiveness. <h3>Methods</h3> ADViSE was developed and implemented in two sexual health clinics (Site 1 and 2) using a mixed methods design: quantitative analysis of electronic patient records and qualitative analysis of staff interviews, written feedback and anonymised cases. The intervention comprised electronic prompts, multidisciplinary training sessions, clinic materials, and specialised referral pathways to advocate-educators (AE). The pilot lasted 7 weeks at Site 1 and is ongoing at Site 2 to last 12 weeks. <h3>Results</h3> Site 1 achieved a 10% enquiry rate (N = 267), 6% disclosure rate (n = 16) and 8 AE referrals. At 8 weeks, Site 2 has achieved a 60% enquiry rate (N = 2113), a 4.5% disclosure rate (n = 90) and 9 AE referrals. Staff reported increased confidence in identifying and managing DVA. No DVA cases were recorded in the 3 months preceding the pilots. <h3>Conclusion/recommendations</h3> IRIS ADVISE can be successfully developed and implemented in sexual health clinics, fulfilling an unmet need for DVA training. Further evaluation through a larger multicentre study is now necessary.

Women’s experiences of referral to a domestic violence advocate in UK primary care settings: a service-user collaborative study

Women experiencing domestic violence and abuse (DVA) are more likely to be in touch with health services than any other agency, yet doctors and nurses rarely ask about abuse, often failing to identify signs of DVA in their patients. To understand women's experience of disclosure of DVA in primary care settings and subsequent referral to a DVA advocate in the context of a DVA training and support programme for primary care clinicians: Identification and Referral to Improve Safety (IRIS). A service-user collaborative study using a qualitative study design. Recruitment was from across IRIS trial settings in Bristol and Hackney, London. Twelve women who had been referred to one of two specialist DVA advocates (based at specialist DVA agencies) were recruited by a GP taking part in IRIS. Women were interviewed by a survivor of DVA and interviews were recorded and transcribed verbatim. Analysis was thematic using constant comparison. GPs and nurses can play an important role in identifying women experiencing DVA and referring them to DVA specialist agencies. GPs may also have an important role to play in helping women maintain any changes they make as a result of referral to an advocate, by asking about DVA in subsequent consultations. A short time interval between a primary care referral and initial contact with an advocate was valued by some women. For the initial contact with an advocate to happen as soon as possible after a primary care referral has been made, a close working relationship between primary care and the third sector needs to be cultivated.

Cost-effectiveness of Identification and Referral to Improve Safety (IRIS), a domestic violence training and support programme for primary care: a modelling study based on a randomised controlled trial

ObjectiveThe Identification and Referral to Improve Safety (IRIS) cluster randomised controlled trial tested the effectiveness of a training and support intervention to improve the response of primary care to women...