Navigating the domestic violence system: What does integration look like for victim-survivors?

Violence, abuse, and neglect are significant public health issues. The Australian Child Maltreatment Study found that approximately 44 per cent of all young people aged 16 to 24 have been exposed to domestic and family violence (DFV), over 25 per cent experience sexual abuse, and 10 per cent experience neglect. The Study highlighted the co-occurrence of DFV with other forms of violence, abuse, and neglect, the associations with other health conditions and experiences of maltreatment, and the intergenerational nature of DFV. Children who experienced DFV were more likely to experience or perpetrate violence in their own relationships later in life.

Yet, too often, health systems provide a response that is fragmented and crisis-driven, rather than one that is holistic, seamless, and person- and family-centred. In 2019, as part of its efforts to improve service integration within and beyond the health system, NSW Health introduced the Integrated Prevention and Response to Violence, Abuse and Neglect (IPARVAN) Framework. The IPARVAN Framework offers guidance to local health districts and speciality health networks across NSW to enhance service access, integration, and coordination for people who experience violence, abuse, and neglect.

We worked with NSW Health to develop an innovative evaluation method that allowed us to measure implementation of the framework and to what extent – and how – system integration contributed to improved outcomes.

When measuring integration, it’s important to first define it. The IPARVAN framework defines integrated services as “the provision of service responses, in accordance with a person-centered approach, that provides seamless care across multiple services, adopts a multidisciplinary and trauma-informed approach, and is designed around the holistic needs of the individual throughout the life course.”

An integrated public health approach recognises that people affected by violence, abuse and neglect often have complex needs requiring multiple interventions and a range of services that may change over time.

The IPARVAN Framework identified four objectives that would lead to greater integration:

• strengthen leadership, governance and accountability;

• enhance skills, capabilities and confidence of the NSW Health workforce;

• expand violence, abuse and neglect services to ensure they are coordinated, integrated, and comprehensive; and

• extend the foundations for integration across the whole health system.

The aim of the evaluation was to measure progress towards integration (both within violence abuse and neglect services and across the whole health system), whether this improved experiences and outcomes for victim survivors of violence, abuse and neglect (including DFV), and the sustainability of the NSW health system.

There were three challenges to demonstrating a causal link between implementation and outcomes, all of which are common to service system-wide evaluations:

• there was no official start date for implementation and no comparator group where implementation had not yet commenced;

• implementation occurred at different rates in different locations; and

• implementation activities varied, as they were tailored to local context (each district or network invested in the resources and services that reflected their unique context and priority).

To respond to these challenges, we developed a mixed methods approach looking at the change in level of integration within each local health district or speciality health network, and change in outcomes within each local health district or speciality health network, to determine whether there was an association between integration and outcomes.

We conducted an extensive literature review and worked with NSW Health to identify a set of 13 integration indicators. We used these to assess local integration through regression and factor analysis, as well as synthesising information from consultations with NSW health staff, data from a self-assessment tool and provider survey, and consultations with clients accessing violence abuse and neglect services.

The analysis conducted by Nous identified five activities to have a positive relationship with progress towards successful integration. These were joint case management, client journey-mapping, 24-hour crisis responses, local evaluation activities, and a focus on service improvement.

It is vital to hear about integration from those who have had experience seeking and/or accessing violence, abuse and neglect support services, as well as the staff delivering the services.

We conducted site visits to nine locations to understand what was happening at a local level. These included visits to two specific locations to meet with Aboriginal clients and Aboriginal staff delivering support services through community-controlled organisations and government. The site visits represented a cross section of rural, metropolitan, and state-wide health services to enable a deeper understanding of the impact of the Framework in different contexts.

We drew on the principles of a trauma informed approach to ensure clients felt safe and empowered to engage in the evaluation. Among other things, this included considerations around how interviewees were selected, the consent process, the remuneration provided to them, who conducted the interviews, and where and when the interviews were held.

“It takes a lot for an individual to share their story, particularly a story of this nature, given the recent experiences of trauma and pain,” says director Georgia Stern. “But these are the stories that bring the data to life. They help explain where the challenges are to getting the support that’s needed and helps to show all the little moments that matter along the way.”

We set up community-controlled governance through an Aboriginal Reference Group to ensure the research and impact of the evaluation on Aboriginal communities was led by Aboriginal people and represented the views of the community. The group had oversight on the consultation approach, interpretation of findings, and how the report was communicated.

With this governance in place, we were able to better assess and document the experiences of Aboriginal people and communities, which differed from the experiences of non-Indigenous people and staff.

We worked closely with NSW Health to understand their agenda, implementation context, and data landscape, developing an evaluation approach that was both rigorous and practical. This involved numerous workshops and working sessions to discuss, test, and finalise the elements of the evaluation framework, including evaluation principles, methodology, ethics, governance, and an analysis plan.

Throughout the evaluation we balanced collaboration with independence. We were collaborative in our approach to the design of the evaluation and monitoring framework that met the needs of NSW Government. This included aligning to evaluation and Treasury guidelines and responding to the realities of a devolved health model, where different activities were implemented at different times in different contexts. We exercised our independence in our approach to consultations and analysis, presentation of insights, and our writing of the reports.

We were also collaborative in how we tested and contextualised findings with our client stakeholders and governance groups. NSW Health had a close to real-time view of findings that supported ongoing implementation, while testing ideas at the right times with the right governance groups led to a more rigorous and credible final report.

“This approach is critical for a successful evaluation,” says director Holly Norrie. “In this case, the successful partnership we built, with a clear understanding on our independence as evaluators, contributed greatly to addressing challenges as they arose, allowing us to delve deeper into analysis and stories and engage stakeholders in a way that was inclusive but not overburdensome.”

The M&E framework and the final evaluation report were released in 2021 and 2022 and are now available on NSW Health website.

The reports supported NSW Health to understand what was working, where and why, and where enhancements could be made. The reports have informed work of PARVAN teams across the health system to improve integration between services and ultimately, experiences for victim-services. This includes integrated governance, multi-disciplinary models of care, multi-agency case management and safety planning, and better data and information sharing. PARVAN teams are also improving how they partner with other services that support victim-survivors, including health, justice, child and family and Aboriginal community-controlled services.

We are continuing to work with NSW Health to support responses to violence, abuse and neglect, including work to help inform a statewide model of care for DFV crisis responses in the health system.

“It’s been great to continue working with the PARVAN team at the Ministry of Health and to see the impact of their work across the last few years in various parts of the system,” says director Holly Norrie. “In recent consultations, in a few different regions, we’ve heard stories of early identification of people who had experiences of DFV and the way that the system came together to quickly direct them to the right specialist response. This is significant progress”