The hidden pandemic: Student perspectives on domestic violence education

Introduction Family violence refers to threatening or other violent behaviours within families that may be physical, sexual, psychological, or economic, and can include child abuse and intimate partner violence (Peterman et al. 2020, van Gelder et al. 2020). Family violence during pandemics is associated with a range of factors including economic stress, disaster‐related instability, increased exposure to exploitative relationships, and reduced options for support (Peterman et al. 2020). Due to the social isolation measures implemented across the globe to help reduce the spread of COVID‐19, people living in volatile situations of family violence are restricted to their homes. Social isolation exacerbates personal and collective vulnerabilities while limiting accessible and familiar support options (van Gelder et al. 2020). In many countries, including Australia, we have already seen an increase in demand for domestic violence services and reports of increased risk for children not attending schools (Duncan, 2020), a pattern similar to previous episodes of social isolation associated with epidemics and pandemics (Boddy, Young & O’Leary 2020). In Australia, as stay‐at‐home orders came into force, the police in some parts of the country reported a 40% drop in crime overall, but a 5% increase in domestic abuse call‐outs (Kagi 2020). At the same time in Australia, Google reported a 75% increase in Internet searches relating to support for domestic abuse (Poate 2020). This pattern is repeated internationally. Reports of domestic abuse and family violence have increased around the world since social isolation and quarantine measures came into force. Recently, anecdotal evidence from the United States, China, Brazil, and Australia indicates increases in intimate partner, women, and children violence due to isolation and quarantine (Campbell 2020; Peterman et al. 2020; van Gelder et al. 2020). China, the first country to impose mass quarantine in the Wuhan province, saw reported domestic abuse incidents rise threefold in February 2020 compared to the previous year (Allen‐Ebrahimian 2020). As Europe imposed quarantine measures in an effort to slow the tide of infection, the Italian government began commissioning hotels to provide shelter to the increasing number of people fleeing abusive situations (Davies & Batha 2020). Similarly, France reported a 32% ‐ 36% increase in domestic abuse complaints following the implementation of self‐isolation and quarantine measures (Reuters News Agency 2020). France also began commissioning hotels as shelters for those fleeing abuse. As quarantine measures extended to the United States, individual states reported similar increases in domestic abuse incidents ranging from 21% to 35% (Wagers 2020). Back in Europe, the UK has also seen concerns about increase in family violence (Bradbury‐Jones & Isham 2020). There have been reports of homicide associated with family violence in several countries (Bradbury‐Jones & Isham 2020; Reuters News Agency 2020). The National Domestic Abuse Hotline in the UK saw a 25% increase in calls since stay‐at‐home measures were implemented (Kelly & Morgan 2020), recording at least eight family violence‐related deaths (Knowles 2020). Isolation and family violence As the novel coronavirus outbreak has intensified globally, countries are adopting dedicated measures to slow the spread of the virus through mitigation and containment (van Gelder et al. 2020; Campbell 2020). Social distancing and isolation are central to the public health strategy adopted by many countries, and in many settings, penalties are in place for any person who breaches these imposed restrictions. Social isolation requires families to remain in their homes resulting in intense and unrelieved contact as well as the depletion of existing support networks, such as through extended family as well as through social or community‐based support networks for families at risk. Additionally, isolation places children at greater risk of neglect as well as physical, emotional, sexual, and domestic abuse (National Society for the Prevention of Cruelty to Children [NSPCC] 2020). Due to (necessary) imposed social distancing and isolation strategies, and the resulting shortages of essential resources and economic consequences of these measures, people globally are living under stressful conditions. While social isolation is an effective measure of infection control, it can lead to significant social, economic, and psychological consequences, which can be the catalyst for stress that can lead to violence. A perfect storm Isolation paired with psychological and economic stressors accompanying the pandemic as well as potential increases in negative coping mechanisms (e.g. excessive alcohol consumption) can come together in a perfect storm to trigger an unprecedented wave of family violence (van Gelder et al. 2020). In Australia, as social distancing measures came into place, alcohol good sales rose more than 36% (Commonwealth Bank Group 2020), and as restaurants, bars, and pubs closed, people are now drinking more within the confines of their homes. Unemployment figures around the world have rapidly risen into the double digits, with millions signing up for welfare payments and a worldwide recession predicted in the near future (Kennedy 2020). Substance misuse, financial strain, and isolation are all well‐known domestic abuse risk factors (Richards 2009). During isolation, there are also fewer opportunities for people living with family violence to call for help. Isolation also helps to keep the abuse hidden with physical or emotional signs of family violence and abuse less visible to others (Stark 2009). COVID‐19 and coercive control Reports show that COVID‐19 is used as a coercive control mechanism whereby perpetrators exert further control in an abusive relationship, specifically in the use of containment, fear, and threat of contagion as a mechanism of abuse. In Australia, charities providing support to people experiencing domestic abuse have highlighted concerns specifically related to reports from people whose intimate partners are using COVID‐19 as a form of abuse. There have been reports of misinformation used by intimate partners related to the extent of quarantine measures (Gearin & Knight 2020) and other forms of COVID‐19‐related abuse (Fielding 2020). Further, there are reports that those experiencing domestic abuse may be afraid to go to hospital for fear of contracting COVID‐19 (Fielding 2020). Reimagining support networks for people living with family violence during these challenging times We recognize that these are challenging times for all of us, but especially for the most vulnerable families and children. The United Nations Secretary‐General Antonio Guterres recently called for countries to prioritize support and set up emergency warning systems for people living with family violence (News Wires 2020). Pharmacies and grocery stores in France are now providing emergency warning systems to help enable people to indicate that they are in danger and need support (Guenfound 2020), through the introduction of code words to alert staff they need help (Davies & Batha 2020). Domestic abuse support agencies in some areas have published specific guidance on domestic abuse in COVID‐19 focussing on what friends and family can do to support people who are isolated (Domestic Violence Resource Centre Australia [DVRCA] 2020). Charities are also recognizing the role that neighbours can play in supporting people living with family violence, providing advice on what to listen for and look for while they themselves are home, and encouraging conversation with neighbours (Gerster 2020). Conclusion The fear and uncertainty associated with pandemics provide an enabling environment that may exacerbate or spark diverse forms of violence. Actions such as social distancing, sheltering in place, restricted travel, and closures of key community resources are likely to dramatically increase the risk of family violence (Campbell, 2020). Governments and policymakers must create awareness about an increased risk of violence during pandemics and highlight the need for people to keep in touch with each other (while observing precautionary measures) and the great importance of reporting any concerns of abuse. It is important to remember that maintaining social connectedness is an important strategy during times of isolation (Usher et al. 2020), even more so with family or friends you suspect may be at risk of family violence. In addition, information about services available locally (e.g. hotlines, tele‐health, respite services, shelters, rape crisis centres, and counselling) must be made known to the general public through a range of sources, including social media, the mainstream media, and health facilities. Mental health professionals can support people by providing first‐line psychological support, including listening empathetically and without judgment, enquiring about needs and concerns, validating peoples’ experiences and feelings, enhancing safety, and connecting people to relevant support services (WHO 2020).

Multiple studies have shown that the majority of health care practitioners do not routinely screen for intimate partner violence (IPV); lack of provider preparedness and education is an often-cited barrier to screening. Our third-year family medicine clerkship includes a pregnancy options counseling objective structured clinical examination (OSCE) that requires students to review a preencounter online educational module that highlights screening guidelines for IPV and reproductive coercion. The goal of this study was to explore students’ internal barriers to screening patients for IPV and reproductive coercion, and whether our curricular interventions adequately addressed these barriers. We administered an immediate postencounter, anonymous, online survey with open-ended and Likert-type questions to 118 medical students during the 2016 academic year. We used an exploratory, iterative process to analyze qualitative responses and quantify recurrent and commonly identified themes. After the OSCE, students reported they were more likely to screen for IPV (94%) and reproductive coercion (82%) in future encounters. Qualitative analysis revealed two major types of barriers to screening: internal barriers concerning the screening inquiry itself and concerns regarding handling of patients’ responses. The online preparatory module and subsequent OSCE provided a low-stakes environment in which to practice screening. However, student comments about their barriers to screening suggest that a first or early curricular intervention folding IPV and reproductive coercion into an educational module on pregnancy options counseling did not optimally promote this screening behavior.