Invisible and Silenced: Improving Healthcare Screening Tools for Women Experiencing Domestic and Family Violence in Rural Communities

By Cleo Wee, Curtin University, WHA, 2023

Executive Summary

Domestic and family violence (DFV) affects people of all ages, genders and backgrounds, but it predominantly impacts women and children and has a significant impact on physical and mental health (Australian Institute of Health and Welfare (AIHW), 2022). Women in rural and remote Australia face additional barriers such as lack of services and inadequate screening/assessment of DFV risk factors that are specific to rural/remote communities.  

This policy paper aims to identify and discuss additional barriers that DFV victim-survivors living in rural/remote Australian communities face. This paper recommends:

Australia's National Research Organisation for Women’s Safety (ANROWS) establishes an additional DFV screening and risk assessment tool that is specifically tailored for rural communities, beginning with a pilot program in Western Australia with WA Country Health Services (WACHS). Conduct an audit after 12 months to determine the efficacy of implementing this tool in detecting DFV and referring patients to appropriate further services. 

Success of this recommendation would be defined as a statistically significant quantitative increase in DFV detection in rural communities and subsequent referral of patients to further DFV services. Funding of approximately $359, 000 should be sourced from the National Plan to End Violence Against Women and Children in order to hire the appropriate researchers, coordinators and auditors from WACHS, ANROWS and the Australian National Audit Office (ANAO).

Identified barriers include inadequate training for healthcare staff which in turn leads to a lack of routine DFV screening/assessment. Suggestions to overcome this include implementing a nationally accredited training program as part of paid professional development leave for healthcare workers.

Problem Identification

In Australia, 1 in 4 women experience violence by an intimate partner or family member, compared to 1 in 16 men (ACT Government, 2022; Mission Australia, n.d.). Nearly one third of Australian women live in rural, regional or remote areas, which is defined by the AIHW as all communities “located in areas outside of Australia’s major cities”, as per the Australian Standard Geographical Classification, and are more likely than their metropolitan counterparts to experience DFV (AIHW, 2022; National Rural Women’s Coalition, 2021). For the purpose of this policy paper, the terms ‘rural’, ‘regional’ and ‘remote’ will be used interchangeably. 

Despite a large proportion of women living in rural/remote communities, DFV screening tools are often designed with a 'metro-centric' focus and may not fully consider the additional barriers women living in rural locations face (Australian Government Department of Health and Aged Care, 2022). Current screenings and assessments of DFV are usually questionnaires that are conducted by healthcare workers. These screening and assessment tools could be improved by incorporating rural-centric risk factors into the assessment, enabling a more thorough and accurate assessment of the severity of a patient’s situation; particularly those who live in rural/remote communities.

Context

Health impacts of domestic and family violence

DFV contributes more to the burden of disease (the impact of illness, disability and premature death) in women of reproductive age (18-44 years) than any other risk factor, such as smoking, alcohol and obesity (Australian Government Department of Health and Aged Care, 2022). The negative health impact of DFV can be broken down into four main areas: mental (e.g. depression and post-traumatic stress disorder), behavioural (e.g. harmful substance abuse, self-harm and suicide attempts), sexual and reproductive (e.g. unwanted pregnancy, sexually transmitted infections including HIV, chronic pelvic infections/urinary tract infections,) and physical and physical complications (e.g. acute/immediate injuries such as bruises, lacerations, fractures and- in worse case scenarios- death) (WHO, 2012). There are also chronic health problems to consider such as chronic pain syndromes, high blood pressure and long-term disabilities caused by more serious injuries (WHO, 2012). 

Domestic and family violence in rural and remote areas

Women living in rural/remote communities are 24 times more likely than women in major cities to be hospitalised as a result of DFV (Community Legal Centres NSW n.d.). This is due to an additional range of complex and multifactorial barriers encountered when escaping DFV such as geographical location, availability of services and willingness to use these services due to the social and cultural characteristics of living in smaller communities (Australian Government Department of Health and Aged Care, 2022). Examples of sociocultural differences between metro and rural/remote communities include acceptance of violence and victim blaming attitudes, availability of weapons such as firearms and familiarity with service providers and law enforcement that exacerbate concerns like anonymity and dual relationships with service providers (Ragusa, 2012).

Screening and assessing for domestic and family violence

Healthcare workers, particularly nurses, are often the first and sometimes only point of contact for people seeking healthcare following DFV incidents (Aljomale et al., 2022). In Australia, every state and territory has their own screening and assessment tools that healthcare providers use to conduct screening and risk assessments for DFV (Government of Western Australia, 2023). 

For example, Western Australia uses the Common Risk Assessment and Risk Management Framework (CRARMF) screening and risk assessment tools (Government of Western Australia, 2023). The CRARMF is a questionnaire combining yes/no checkboxes assessing DFV risk factors such as the perpetrator harming the patient, children or family member along with short answer questions that allow the healthcare provider to explore these risk factors in more detail (Government of Western Australia, 2023). 

New South Wales (NSW), on the other hand,) uses the Domestic Violence Safety Assessment Tool (DVSAT) (NSW Government Department of Communities and Justice, 2018). The DVSAT is structured as a questionnaire and point-scoring system. There are similarities across the state-based tools, for example both the CRARMF and DVSAT ask if the perpetrator has ever threatened, stalked or harmed the victim and/or children in the household. Both tools also ask if the abuser has access to firearms or prohibited weapons along with the psychiatric and forensic history of the abuser (NSW Government Department of Communities and Justice, 2018).

These tools are often designed from a ‘metro-centric’ viewpoint, and considers risk factors primarily in a metropolitan setting (Australian Government Department of Health and Aged Care, 2022). Thus, these tools may not fully consider the additional barriers women living in rural locations face (Australian Government Department of Health and Aged Care, 2022). 

Current policies and stakeholders 

Australia currently has two key national policies in place to address the issue of DFV towards women and girls in rural areas: The National Plan to End Violence against Women and Children (the National Plan) 2022–32 (Department of Social Services, 2022) and the National Women's Health Strategy (NWHS) 2020–30 (Australian Government Department of Health and Aged Care, 2022). The federal Department of the Prime Minister and Cabinet’s Office for Women implements the National Plan and the NWHS, as part of the National Strategy to Achieve Gender Equality (National Strategy to Achieve Gender Equality, 2022).

The National Plan 2022-32 states “women living in rural and regional areas face additional barriers to accessing support” for gender-based violence (Department of Social Services, 2022). However, it does not provide strategies or suggestions for addressing these barriers. The National Plan provides direct funding to Australia’s National Research Organisation for Women’s Safety (ANROWS) and is responsible for promoting information and resources, direct funding and service delivery (ANROWS, 2022). ANROWS’ stakeholders include government policymakers and practitioners from the domestic, family and sexual violence, primary prevention and wider health researchers, justice and human services sectors (ANROWS, 2022).

The NWHS 2020-30 outlines service delivery, educating the broader health workforce, public information promotion and supporting research centres (Australian Government Department of Health and Aged Care, 2022). It states that one of its priorities is to address the ‘metro-centric’ assumptions in health care design, access and delivery that often exacerbates the poorer health outcomes of women in rural areas compared to women living in metropolitan areas (Australian Government Department of Health and Aged Care, 2022). It also mentions “designing and delivering safe and accessible services” for women experiencing DFV is 1 of the 3 key priorities for reducing health impacts of violence against women (Australian Government Department of Health and Aged Care, 2022). However, the NWHS does not go into further detail on how it aims to make these services more rural-centric and accessible, nor does it discuss funding required to improve these services.

Each Australian state and territory has a DFV policy outlining strategies and objectives to reduce DFV: 

State/territory	Domestic and family violence policy
Western Australia	Path to Safety: Western Australia’s Strategy to Reduce Family and Domestic Violence 2020 – 2030 (Government of Western Australia, 2023)
Northern Territory	Domestic, Family & Sexual Violence Reduction Framework 2018–2028 (Northern Territory Government, 2018)
South Australia	South Australia Housing Authority Domestic Abuse Policy (Government of South Australia, 2022)
Queensland	Domestic and family violence prevention strategy 2016-2026 (Queensland Government, 2023)
New South Wales (NSW)	NSW Health Policy and Procedures for Identifying and Responding to Domestic Violence (NSW Government, 2018)
Victoria	Free from Violence – Second Action Plan 2022–2025 (Victorian Government, 2022)
Australian Capital Territory (ACT)	ACT Public Service Domestic and Family Violence Policy (ACT Government, 2018)

The state/territory policies discuss DFV in rural and remote communities at various depths, with most only briefly mentioning that women living in remote and rural communities are at higher risk of DFV. The NSW policy goes into the most detail, listing risk factors specific to rural/remote communities that women and children face. These risk factors are discussed in the case study below. 

Case studies 

Case Study 1 - NSW: 

The NSW Health Policy and Procedures for Identifying and Responding to Domestic Violence (NSW Government, 2018) outlines a list of risk factors specific to women and children living in rural/remote areas: 

1. Increased isolation from friends and extended family 

2. Having limited or no access to health, counselling and support services in their area 

3. Having heightened concerns around confidentiality arising from living in a small community

4. Having limited or no access to public transport that reduces the ability of the women to seek safety or receive assistance 

5. Lack of safe emergency and longer term housing options in the area 

6. The greater risk of injury for families living on farms or in isolated dwellings due to longer police travelling times 

7. The loss of support networks when leaving an abusive relationship means having to leave the area 

8. The widespread availability and serious risk posed by firearms.

It suggests that healthcare workers should consider specific safety issues faced by isolated patients and make use of telephone services to increase access to support services. However, it does not mention if the rural and remote-specific risk factors listed above are routinely assessed by healthcare workers. 

Case Study 2 - Canada: 

The Canadian Domestic Homicide Prevention Initiative (CDHPI) has conducted research which affirms that few DFV tools have been specifically tailored for rural communities (CDHPI, 2019). There are many DFV perpetrator-based risk assessment tools designed to assess risk of re-offending, severe violence and/or lethality but even these tools are not designed with rural/regional communities in mind (CDHPI, 2019). The CDHPI publication Domestic Violence and Homicide in Rural, Remote, and Northern Communities: Understanding Risk and Keeping Women Safe includes a list of recommended additions to screening tools that would address risk factors specific to rural communities (CDHPI, 2019). These recommendations include: 

1. Distance from the closest neighbour

2. Access to a telephone and transportation

3. Access to and distance from social support 

4. Awareness of and willingness to use nearby services 

5. Perpetrator misuse and abuse of firearms 

6. Perpetrator abuse of pets and farm animals 

Policy Recommendations

The following recommendation is proposed to address the lack of screening for rural and remote risk factors of DFV. It is recommended: 

1. ANROWS establishes an additional DFV screening and risk assessment tool that is specifically tailored for rural communities, beginning with a pilot program in Western Australia with WA Country Health Services (WACHS). 

It is recommended that both ANROWS and WACHS design and implement the rural-centric DFV screening and assessment tool in partnership with each other. As the lead body in charge of research relating to DFV, it is recommended that ANROWS identify the gaps in the CRARMF tool (DFV risk factors specific to rural communities) and oversees the design of adjunct screening tool. 

It is recommended that ANROWS uses the recommendations in CDHPI publication Domestic Violence and Homicide in Rural, Remote, and Northern Communities: Understanding Risk and Keeping Women Safe as a guide to identify rural-specific risk factors that should be incorporated into the adjunct screening and assessment tool (CDHPI, 2019).

It is proposed that WACHS implements the adjunct tool, with the project led by a Health Promotion Coordinator who liaises with ANROWS. WACHS is the largest country health system in Australia and provides comprehensive healthcare to people living rural and remote areas across Western Australia via the following services: (WACHS, 2021)

1. 6 large regional hospitals

2. 15 medium sized district hospitals

3. 48 small hospitals

4. 31 health centres and nursing posts

5. 24 community-based mental health services

6. 4 dedicated inpatient mental health services

7. 178 facilities where population health teams are based

It is proposed that these services would be the most suitable for introducing the new adjunct DFV tool.

Costings

The cost of hiring a full-time Senior Research Officer at ANROWS is approximately $122,000 per annum (ANROWS, 2023). The cost of hiring a full-time Health Promotion Coordinator at WACHs is approximately $110,000 (Department of Health, 2023). Funding could be sourced from the National Plan which has been allocated $328.2 million from the 2022-23 Federal Budget over five years for measures targeting early intervention of DFV  (Parliament of Australia, 2022).

Monitoring and Evaluation 

An audit of the Recommendation would enable a quantitative measure of the efficacy of the adjunct DFV tool. The proposed audit will provide data that can contribute towards the National Plan’s specific and measurable indicators of success, specifically: (Department of Social Services, 2022)

1. Increase in proportion of victim-survivors seeking advice and support 

2. Increase in capacity of frontline services to meet demand

The Western Australian Safety and Accountability Audit of the Armadale Domestic Violence Intervention Project (ADVI) conducted a successful audit in 2007 analysing interventions and responses to DFV, with a specific focus on the intersection of child protection, the criminal justice system and advocacy in DFV cases (Pence et al., 2007). Collation of the audit findings produced a detailed review into the responses from Western Australian DFV services to DFV survivors, and identified areas for improvement, suggesting methods of collaboration between DFV service stakeholders in Western Australia to improve service delivery and protection of women and children from further abuse (Pence et al., 2007). One of the biggest successes of this audit was the Government of Western Australia developing an interagency system for gathering, documenting and sharing information on DFV cases which then enables government and non-government workers to intervene in timely and effective ways  (Pence et al., 2007). 

It is recommended the Australian National Audit Office (ANAO) lead this audit partnership with WACHS and participating rural communities/healthcare services. Based on the Coordination and Targeting of Domestic Violence Funding and Actions Auditor-General Report by the Australian National Audit Office (ANAO), it costs $509,000 annually to hire four staff members to execute a national audit (Parliament of Australia, 2020). By population size, Western Australia is home to roughly 10% of the national population. Thus, it is calculated that one full-time staff member ($509,000 /4 = $127,250 p.a.) will be adequate to conduct a state-wide audit. Funding could be sourced from the National Plan (Parliament of Australia, 2022).

Success of the recommendation would be defined as a statistically significant quantitative increase in DFV detection in rural communities and subsequent referral of patients to further DFV services. It is proposed the audit is structured in a similar manner to the ADVI audit, with three phases (preparation, data-collection and analysis). During the first (preparation) stage, the audit objective and criteria will be defined by ANAO, WACHS and relevant healthcare leaders in participating communities. The data-collection stage will involve compilation of relevant documentation, conducting interviews with first-line healthcare workers/responders and patients who have experienced or are seeking support for DFV.  

It is recommended that on-site visits are conducted where possible; however, the WACHS telehealth services could possibly be used as an alternative if face-to-face interviews are not possible (Government of Western Australia, 2023). It is proposed that the analysis stage includes reporting of findings and subsequent recommendations. 

Data such as previous referrals to DFV services can be obtained from the WACHS database which has historically supported large cohort studies (Government of Western Australia, 2023). This would also align with the WACHS Research and Innovation Strategy 2019-24 (Government of Western Australia, 2023).

Limitations/Barriers

Less than a third of healthcare staff routinely ask patients about DFV and around 35% reported they did not have sufficient training to assist patients experiencing DFV (Creedy et al., 2021). Screening for and detecting DFV in clinical settings is currently subpar in Australia, where 70% of women experiencing DFV go undetected by healthcare staff. (Creedy et al., 2021) The Australian Government has a nationally accredited 3-day DFV training program called DV-alert (DV-alert). It is complementary for frontline workers and has an in-person or online option; however, it is not mandated for healthcare staff (DV-alert). Mandating the DV-Alert training would be taken out of healthcare workers’ own time. Depending on the agreement with their employer, this may result in 3 days of unpaid leave. However, this could be remediated by negotiation between employer and employee, as many healthcare workers are allocated paid professional development leave. A shorter training program to ensure all staff are at least aware of their state-based DFV tool and adjunct rural-centric DFV tool could be an alternative to this longer 3-day program. 

Further limitations include the hesitation from women to undergo DFV screening/assessment or be referred for further services. In these instances, accredited training such as the DV-alert course would better-equip healthcare workers to deal with the complex and varied factors that could affect a patient’s willingness to receive DFV support.  

Conclusion 

Women living in rural/remote communities who experience DFV face significant disadvantages compared to their metropolitan counterparts when accessing support and healthcare services. It is crucial that the screening and assessment tools used by healthcare workers, particularly those working on the frontline, address and assess the additional risk factors that women in rural/remote settings experience. 

Introducing an adjunct that addresses these rural-centric DFV risk factors would address the current inequities in our metro-centric DFV screening and assessment tools and enable our healthcare workers working in rural/remote settings to detect and refer victim-survivors of DFV to relevant services. 

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