Identification and Referral to Improve Safety (IRIS) of women experiencing domestic violence with a primary care training and support programme: a cluster randomised controlled trial
Identification and Referral to Improve Safety (IRIS) of women experiencing domestic violence with a primary care training and support programme: a cluster randomised controlled trial
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DOI：
10.1016/s0140-6736(11)61179-3
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发表时间：
2011-11-19
期刊：
影响因子：
168.9
通讯作者：
Sharp, Debbie
中科院分区：
文献类型：
--
作者：
Feder, Gene;Davies, Roxane Agnew;Sharp, Debbie
背景大多数临床医生没有接受过关于家庭暴力的培训，无法识别遭受虐待的患者，并且在披露后对管理不确定。我们测试了初级保健实践方面的培训和支持计划的有效性，以增加对遭受家庭暴力的妇女的识别和她们向专家倡导服务的转介。方法在这项整群随机对照试验中，我们选择了两个城市初级保健信托基金的一般实践，Hackney(伦敦)和Bristol，UK。受雇于这项试验的调查员或不使用电子记录的人的做法被排除在外。根据女性医生的比例、研究生培训状况、登记的患者数量和低收入执业人口的百分比对执业进行分层。在每个初级保健信托领域，我们通过一个计算机最小化程序将实践随机化，并将随机成分分配给干预组或控制组。干预方案包括以实践为基础的培训课程，在医疗记录中提示询问虐待情况，以及转介给一位指定的家庭暴力倡导者，后者也提供了培训和进一步的咨询。主要结果是将患者转介到家庭暴力宣传服务机构。预先规定的次要结果被记录在全科医生的电子医疗记录中，以确定家庭暴力。对接受干预的所有实践进行了泊松回归分析，说明了分组情况。实习人员和研究助理没有戴面具，患者也不知道他们是研究的一部分。这项研究在当前对照试验中注册，ISRCTN74012786。我们在哈克尼和布里斯托尔随机抽取了84家符合条件的全科医生中的51人(61%)。在这些人中，24人接受了培训和支助方案，24人没有接受方案，3人在试验开始前辍学。第二次培训1年后，24项干预措施记录了223例患者转诊至宣传，24项对照措施记录了12例转诊(调整后的干预率比22.1[95%可信区间11.5-42.4])。干预措施记录了641起披露家庭暴力的事件，控制措施记录了236起(调整后的干预比率为3.1[95%可信区间2.2-4.3])。没有不良事件的记录。解释针对初级保健临床医生和行政人员的培训和支助方案改善了转介到专门的家庭暴力机构的情况，并记录了遭受家庭暴力的妇女的身份。我们的研究结果减少了家庭暴力初级保健环境中培训和支持干预的益处的不确定性，并表明对女性患者进行家庭暴力筛查并不是改善识别和转介至倡导服务的必要条件。
Background Most clinicians have no training about domestic violence, fail to identify patients experiencing abuse, and are uncertain about management after disclosure. We tested the effectiveness of a programme of training and support in primary health-care practices to increase identification of women experiencing domestic violence and their referral to specialist advocacy services.Methods In this cluster randomised controlled trial, we selected general practices in two urban primary care trusts, Hackney (London) and Bristol, UK. Practices in which investigators from this trial were employed or those who did not use electronic records were excluded. Practices were stratified by proportion of female doctors, postgraduate training status, number of patients registered, and percentage of practice population on low incomes. Within every primary care trust area, we randomised practices with a computer-minimisation programme with a random component to intervention or control groups. The intervention programme included practice-based training sessions, a prompt within the medical record to ask about abuse, and a referral pathway to a named domestic violence advocate, who also delivered the training and further consultancy. The primary outcome was recorded referral of patients to domestic violence advocacy services. The prespecified secondary outcome was recorded identification of domestic violence in the electronic medical records of the general practice. Poisson regression analyses accounting for clustering were done for all practices receiving the intervention. Practice staff and research associates were not masked and patients were not aware they were part of a study. This study is registered at Current Controlled Trials, ISRCTN74012786.Findings We randomised 51 (61%) of 84 eligible general practices in Hackney and Bristol. Of these, 24 received a training and support programme, 24 did not receive the programme, and three dropped out before the trial started. 1 year after the second training session, the 24 intervention practices recorded 223 referrals of patients to advocacy and the 24 control practices recorded 12 referrals (adjusted intervention rate ratio 22.1 [95% CI 11.5-42.4]). Intervention practices recorded 641 disclosures of domestic violence and control practices recorded 236 (adjusted intervention rate ratio 3.1 [95% CI 2.2-4.3). No adverse events were recorded.Interpretation A training and support programme targeted at primary care clinicians and administrative staff improved referral to specialist domestic violence agencies and recorded identification of women experiencing domestic violence. Our findings reduce the uncertainty about the benefit of training and support interventions in primary care settings for domestic violence and show that screening of women patients for domestic violence is not a necessary condition for improved identification and referral to advocacy services.