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Social Science & Medicine 65 (2007) 1742–1750

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‘Health’s a difficult beast’: The interrelationships betweendomestic violence, women’s health and the health sector

An Australian case study

Colleen Fishera,�, Lynne Huntb, Rhonda Adamsamc, Wilfreda E. Thurstond

aEdith Cowan University Joondalup, WA, AustraliabEdith Cowan University, Australia

cGranny Spiers Community House Inc., AustraliadUniversity of Calgary, Alta., Canada

Available online 5 July 2007

Abstract

This paper reports on the Australian component of a five nation study undertaken in Australia, Canada, Thailand,

Bangladesh and Afghanistan examining policy networks that address women’s health and domestic violence. It examines

the relationship between health and domestic violence in Western Australia and analyses the secondary role assumed by

health. The study adopted a qualitative research paradigm and semi-structured interviews. Snowball sampling was used to

identify relevant and significant stakeholders and resulted in a final sample of 30 individuals representing three key areas:

the ‘health policy community’, the ‘domestic violence prevention community’ and ‘other interested stakeholders’, that is,

those who have an interest in, but who are not involved in, domestic violence prevention work. Results suggest that the

secondary positioning of health is associated with the historical ‘championing’ of the issue in the women’s movement;

limited linkages between the health policy community and the domestic violence prevention community and within the

health policy community itself; the ‘fit’ between domestic violence and the Western Australian Health Department

mandate; and the mis-match between domestic violence and the medical model. The conclusion indicates a need for

collaboration based on effective links across the domestic violence community and the health policy community.

r 2007 Elsevier Ltd. All rights reserved.

Keywords: Australia; Domestic violence; Policy; Women; Women’s movement

Introduction

This article reports on the findings of theAustralian component of an international study ofhealth and domestic violence in five countries

e front matter r 2007 Elsevier Ltd. All rights reserved

cscimed.2007.05.047

ing author.

esses: c.fisher@ecu.edu.au (C. Fisher),

d.net (L. Hunt), grannyspiers@swiftdsl.com.au

, thurston@ucalgary.ca (W.E. Thurston).

(Australia, Canada, Bangladesh, Thailand andAfghanistan). It explores possible explanations forthe secondary role taken by health services inWestern Australia. It adds to analyses of the healthimplications for women experiencing domesticviolence (Campbell, 2002; Hegarty, Gunn,Chondros, & Small, 2004; Mouzos, 1999; Parker& Lee, 2002; Quinlivan & Evans, 2001; Resnick,Acierno, & Kilpatrick, 1997; Roberts, Lawrence,O’Toole, & Raphael, 1997; Roberts, Williams,

.

ARTICLE IN PRESSC. Fisher et al. / Social Science & Medicine 65 (2007) 1742–1750 1743

Lawrence, & Raphael, 1998; Taft, 2002; WHO,2002). Further, the study has implications for theorganisation and cost of women’s health care. Forexample, the annual cost to the Australian economyof domestic violence has been estimated to be inexcess of AUD8 billion dollars (Access Economics,2004) of which approximately AUD388 million isattributable to health costs. Despite this, the role ofthe health sector in the process of the preventionand care for victims of domestic violence has beensecondary to that of the legal system in Australia.

Background and context

The legal/judicial system is the cornerstone ofresponses to domestic violence in many westerncountries. Australia is no exception. Criminalsanctions are widely recognised as having animportant role in the process of prevention ofdomestic violence (see for example Busch &Robertson, 1994; Office of Women’s Policy, 2002)because criminalisation has long been acknowl-edged in the literature, and in service provision, asperforming a function that is highly symbolic inreinforcing legal and social norms (Holder, 2001).This being so, those committed to the prevention ofdomestic violence have made considerable efforts toreform the justice system to ensure that it applies thesame standards of non-violence in public places towomen’s intimate relationships. Use of criminaljustice to address domestic violence sits nicely withpolitical realities because governments can be ‘seento be doing something’ about domestic violence.

International research has reinforced the central-ity of the legal system in co-ordinated andintegrated responses to domestic violence (see forexample Domestic Violence Prevention Unit, 2000;Edleson, 1991; Edleson & Tolman, 1992; MinnesotaCenter Against Violence and Abuse, 2001; Pence &Paymar, 1993; Syers & Edleson, 1992). As aconsequence, attention has focused on the needfor a cultural change in police departments tofacilitate appropriate responses to domestic violenceincidents. Initiatives have included mandatoryarrest (Williams & Hawkins, 1992) and, in the civiljurisdiction, the use of violence restraining orders(Family and Domestic Violence Taskforce, 1996;Graycar & Morgan, 1990). In contrast, the role ofthe health sector remains underdeveloped and itsimportance only recently highlighted (Clark,Burt, Schulte, & Maguire, 1996). This is despiteWHO (2002, p. 101) suggesting that women who

experience violence, whether it be in childhood or asan adult,

experience ill-health more frequently, than otherwomen—with regard to physical functioning,psychological wellbeing, and the adoption offurther risk behaviours. A history of being thetarget (sic) of violence puts women at increasedrisk of depression, suicide attempts, chronic painsyndromes, psychosomatic disorders, physicalinjury, gastrointestinal disorders, irritable bowelsyndrome and a variety of reproductive healthconsequences.

This scenario applies to Australian women. Forexample, between 1989 and 1998 in Australia, over57% of deaths in women resulting from homicide orviolence were perpetrated by an intimate partner,with women being over five times more likely to bekilled by an intimate partner than men (Mouzos,1999). Additionally, women reporting domesticviolence are nine times more likely to report havingharmed themselves or having recent thoughts ofdoing so, than women who had never experiencedviolence (Roberts et al., 1997). They are more likelyto use medication for depression and anxiety(Resnick et al., 1997), tranquillisers and sleepingpills (Campbell, 2002), and they are more likely tohave psychiatric disorders (Roberts et al., 1998) anddrug and alcohol problems (Quinlivan & Evans,2001; Roberts, et al., 1997, 1998). Injuries to theireyes, ears, head and neck as well as the breast andabdomen, especially during pregnancy, are commonin women attending Australian hospitals for treat-ment (Campbell, 2002). These health implications ofdomestic violence occur across the lifespan andpersist for many years (Hegarty et al., 2004; Parker& Lee, 2002; Quinlivan & Evans, 2001; Taft, 2002).Clearly, the active engagement of health depart-ments in government policy and responses todomestic violence is vital.

Across-government responses and domestic violence

The domestic violence literature highlights theimportance of responding to victims through theprovision of co-ordinated services within ‘across-government’ frameworks that provide a holisticresponse to the complex issue of domestic violence(Balzer, 1999; Hague, 1998; Hill, 2002; Holder,2001; Humphreys & Holder, 2002; Syers & Edleson,1992). Such a framework can, potentially, delivera seamless support services to women thereby

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enhancing their safety (FDVU, 2004). In WesternAustralia, the responsibility for this policy frame-work lies with the Family and Domestic ViolenceUnit (FDVU) of the Department for CommunityDevelopment and articulated in the FDVU statestrategic plan, which prioritises the co-ordinationand integration of service delivery across govern-ment (FDVU, 2004). The responsible governmentMinister suggests that the state strategic plan issignificant because it ‘means all relevant Ministersand government departments are working togetherunder a single policy framework’ (FDVU, 2004,pp. v–vi). Whilst this policy framework exists, theextent to which it is given more than rhetoricalsignificance requires exploration and is the subjectof this article.

Research methodology

This study adopted a qualitative research para-digm using semi-structured interviews. This ap-proach has many precedents in domestic violence(Best, 2002; Buchbinder & Winterstein, 2003;Nicolaidis, 2002) and allows for the identificationof perspectives salient to respondents. To facilitateaccess to a wide range of participants who wouldadd dimension and depth to the study, snowballsampling was used in which participants identifiedother relevant and significant stakeholders. Thisprocess gave rise to a sample of 30 individualsrepresenting three key areas: the ‘health policycommunity’, the ‘domestic violence preventioncommunity’ and ‘other interested stakeholders’,that is, those that have an interest in, but arenot directly involved in, domestic violence preven-tion work.

Ethical approval for the process and content ofthe interviews was provided by the HumanResearch Ethics Committee of Edith CowanUniversity to undertake the study.

Data collection and data analysis occurredsimultaneously. Individual interviews with the 30participants were transcribed verbatim and im-ported into QSR N6 computer-based qualitativedata analysis programme. ‘Base Nodes’ werecreated in N6 to facilitate coding for the type ofagency the participant represented (e.g., state, Non-Government Organisation [NGO], Academic Insti-tution), the agency classification (in terms of healthpolicy community, domestic violence preventioncommunity, and other interested stakeholders) andthe individual’s role within their respective agency.

Data were then coded to nodes as themes/issuesemerged, and analysed.

Results and discussion

Participants identified a number of lead agenciesin the field of domestic violence: the Women’sCouncil for Domestic and Family Violence Services,Department for Community Development andFDVU, the Western Australian Police Service andLegal Aid Commission of Western Australia.Despite the wide-ranging health implicationsfor victims resulting from experiencing domesticviolence, health agencies were not identified.This could partly be explained by historicalfactors with domestic violence being ‘championed’through the women’s movement—specifically, inWestern Australia, through the women’s refugemovement and the Women’s Council for Domesticand Family Violence Services (McFerren, 1987).This explanation, however, is only partial and theanalysis turned to other reasons for the secon-dary position of health. These were found to be:‘linkages between domestic violence communityand the health sector’, ‘linkages within the healthsector’, ‘disagreement about the fit betweendomestic violence and the Western AustralianHealth Department mandate’, and ‘the medicalmodel’.

Linkages between domestic violence and the health

sector

This study explores the ways in which staff ofdifferent agencies interacts to advance policy for theprevention of domestic violence. In brief, it showsthe linkages between the domestic violence commu-nity and the health sector. This is not an easy task,according to a representative from the FDVU, whodescribed health as a ‘difficult beast’. By this hemeant that the department is large, has manydepartments, and is a bureaucracy with layers ofadministration. This complexity is simplified in thepresent discussion by analysis focused on twoseparate levels: grass roots level and strategic policylevel. However, local health sector policy is oftenaffected by international, national, and regionalpolicies, and these effects may be obscured by thelayers of bureaucracy (Thurston et al., 2005),making the health sector even more of a ‘difficultbeast’.

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Grass roots level

Most of the interaction between the domesticviolence community and the health sector occurs ata ‘grass-roots’ level. In other words, networks andrelationships have developed at individual agencylevel. At times, networks can be particularly strong:

We directly interact with individual people in thehealth sector through women and childrenneeding direct medical assistance y the localdoctors, the local hospital, the local mentalhealth service, so in that sense we would haveone-on-one relationships with individual healthproviders. (Women’s Refuge staff member)We have a good relationship with our local GPsurgery. We have a health nurse that visits y

here in terms of the kids. (Women’s Refuge staffmember)

In addition to relationships between individualagencies, representatives from the communityhealth sections of the Health Department are oftenmembers of various regional domestic violence co-ordinating committees.

We have health sector representatives on our[regional co-ordinating] committee and relation-ships with them [health sector agencies] is (sic)really positive. (F&DV agency staff member)

These committees have responsibility for bringingtogether representatives of the various agenciesdealing with domestic violence in a given region tofacilitate an integrated service response. The HealthDepartment committee members, however, are notsufficiently senior to influence policy directionwithin the department. Hill (2002) provides aframework within which this can be explained. Heargues that any policy discourse requires a context-specific ‘audience’ (p. 1728) and if change is tooccur, the ‘audience’ must be capable of affecting it.Those involved in networking at grass roots levelfrom the health sector are, therefore, not theappropriate ‘audience’ to facilitate improved policyoutcomes in terms of domestic violence.

In summary, there is ongoing networking atgrass-roots level. The relationships between thedomestic violence community and the health sectorat policy level, however, are minimal.

Strategic policy level

Health Department respondents clearly articulatethe need for health issues to be networked to otheragencies in Western Australia that address domestic

violence at a policy level. As one health workernoted:

Our primary responsibility is the treatment ofinjury and the preservation of health and life. Sothat would be the y unique, if you like, area ofservice that this department is responsible forand the more broad areas of responsibilityobviously are the support, social support andthe secondary prevention of, in other words, offurther episodes of violence and our role may notbe that we are able to achieve that alone since weare after all the health system. So we need to havethe networks with services [that] can. (HealthDepartment staff member)

The reality is, however, that despite the cleararticulation of the need for networks, there isminimal networking between health and the domes-tic violence prevention community in general.

Well we [Women’s Council and Health Depart-ment] probably don’t interact as well as weshould. I remember [a couple of years ago]speaking to someone who had been involved inwriting it [a report on domestic violence] andthey didn’t want the Health Department to get soclosely involved with the issue y. So yes it’s,I don’t think they want to make those linksand we probably haven’t been as successful aswe’d like to be with making those links bet-ween women’s health and domestic violence.(Women’s Council for Domestic & FamilyViolence Services member)

It appears from this research that the FDVU isthe ‘lynch pin’ that links the two sectors and ensuresongoing dialogue.

FDVU as a ‘lynch pin’

There has been considerable debate about therelative importance of separatist, grass-roots agen-cies and mainstreamed services for women’s health(Broom, 1991; Hunt, 1998). Grass-roots serviceshave drawn fire because they are often under-fundedand marginalised, and mainstreamed services havebeen condemned for paying inadequate attention towomen’s concerns. This research reveals the im-portance of the middle ground in such debatesbecause it was clear that the FDVU has animportant role as the ‘lynch pin’ that links separatistand mainstreamed agencies. Despite the limitednature of the relationship, the FDVU does ‘bridge

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the gap’ with health services by maintaining on-going dialogue. Indeed, links between the two arereported by FDVU staff as good:

[Our relationship is] Absolutely [fine] on anumber of levels. In terms of our work acrossgovernment, health is critically involved there ywe’ve got strategic alliances with the healthsector around things like screening. So we’reworking with them in developing some screeningtools so that people, that domestic violence isdetected. (FDVU staff member)

However, the relationship is something of a ‘one-way street’ with the FDVU forging networks withthe health sector. Those in the health sector with aninterest in domestic violence are more responsivethan proactive. As a consequence, FDVU staff wereunaware of who to contact beyond those alreadyidentified:

The people we talk to are the people we’ve

identified [emphasis added] that we [emphasisadded] need to have a relationship with and it’sstrong and it’s collaborative and it’s co-opera-tive. But there would be other parts of health thatwe have no relationship with and we don’t know.(FDVU staff member)

This insularity was further highlighted andsupported by a Senior Policy Officer in the HealthDepartment who suggested that, as far as adomestic violence health policy formulation isconcerned, she would consult internally:

Well if you’re talking health policy then you’retalking pretty internally. I know that, in afashion, all policy, the thing is to say you’ll talkto every single living soul, you’ve been with thepulse of the universe, but realistically, I’ll talk toother health people first. This is a health system.It’s trying to do its job. So they’re the first onesthat I’d want in the room y [If you’ve] scannedthe whole health system [and] found out what theproviders y would like to be able to do withinthe orbit of their professional practice y that’swhat we’re [health system] working on. (HealthDepartment staff member).

The lack of cross-sector collaboration is a muchdiscussed issue in population health literature(Degeling, 1995; Thompson, 1994). It is oftenattributed to a lack of willingness or ability ofhealth sector staff to work collaboratively, but itmay reflect ignorance about who to contact

(Abelson, 2000; Abelson & Lomas, 1996). Thechallenge of collaboration is finding common goalsand maintaining communication, both formal andinformal (Scott, Thurston, & Crow, 2002). Somehealth organisations have developed frameworks toguide staff (Maloff, Bilan, & Thurston, 2000), butthe nature of the ‘beast’ may sometimes precludework across sectors, as evidenced in this study.

Linkages within the health sector

Not only are there minimal linkages between thehealth sector and the domestic violence communityat a policy level, but also this scenario is repeated atan intra-departmental level. As the following healthworker indicates, even though she is in close contactwith the departmental policy section, and hasdomestic violence as her sole responsibility, shehas not been privy to policy making processes.

I’ve not been able to be a part of the policymaking.y The policy now on domestic violence,that’s being formulated, I haven’t seen nor have Ibeen involved with it, even though I’m infrequent contact with the person who’s runningthe policies y. (WA Health Department staffmember)

This may suggest that the health sector responseto domestic violence is rhetorical and the positionssymbolic rather than core business; however,population health promotion and prevention havehistorically struggled for priority status in a systemwhere the largest budget and the public’s firstconcern is acute care (Casebeer, Scott, & Hannah,2000).

The fit of domestic violence and the health department

mandate

Given that an estimated AUD388 million arespent annually on health funding to treat victims ofdomestic violence (Access Economics, 2004), thereought to be little debate about the importance ofengaging the health sector in domestic violenceissues at strategic and policy levels. Yet, thisresearch highlighted diametrically opposed viewsregarding the ‘fit’ between domestic violence andhealth, specifically the mandate of the HealthDepartment. One view suggests that there is a‘perfect’ fit between the two, simply becausehospitals provide treatment for victims:

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It’s [the mandate is] the preservation of life andhealth. People who are injured or damaged insome way through accident, injury or whatevery it’s [a] well established part of communityknowledge that, you know, whatever your sourceof injury, you to go to hospital or other parts ofthe health system. (Health Department staffmember)

This view shows, however, that the ‘fit’ may notextend beyond mandated obligations to providetreatment services.

The opposing view, from a respondent who hasdomestic violence as her sole responsibility, suggeststhat the mandate exists and could be extended:

It’s [domestic violence] only being paid lip serviceto. It’s not been addressed. It’s not part ofmandatory reporting. It’s not part of keyperformance indicators. (Health DepartmentStaff Member)

Further,

There is no compulsion for the health services tohave any policy [on domestic violence] soalthough there is a policy there and althoughthe statement to the FDVU was that Departmentof Health staff are obliged, in reality mostDepartment of Health staff don’t even knowthat the policies exist, that the protocols exist,therefore they don’t know what to do about it.(Health Department staff member)

This ambivalence about the mandate of theHealth Department is echoed in perceptions heldby the grass roots domestic violence community. Atthis level there is also doubt about the will of theHealth Department to be proactive:

What they [Health Department] really do is say‘‘No that’s not our issue, it’s y DCD’s [Depart-ment for Community Development’s] issue, it’s afamily issue and it should be resolved within thefamily and it’s just about dysfunctional families.Or it’s a women’s issue’’. So they’re really the twolevels of, response. Or it’s now saying ‘‘It’s apolice issue to remove the perpetrator from thehome or, or arrest him on the spot’’. But health,if you bring it up as a health issue, no they[Health Department] don’t really want to knowthat y. Have you seen anyone in the HealthDepartment that is actually open to the idea?[developing a women’s domestic violence healthpolicy] Would there be anyone within the Health

Department? Not really. (Women’s Council forDomestic and Family Violence Services member)

In summary, the extent of the involvement of theHealth Department in services for victims ofdomestic violence is through the provision ofmedical treatment, the funding of women’s healthand information services and specialised sexualassault resource centres (FDVU, 2004). Individualhealth professionals do provide referrals to supportservices for victims, but being individual in nature,it tends to be ad hoc and there are no standards ofcare as in more traditional medical procedures. Thatis, the service a woman receives is largely a result ofan individual decision by an individual healthprofessional.

Domestic violence and the medical model

The women’s health movement, which emerged aspart of the second wave of feminism in the early1970s, sought to de-medicalise women’s healthissues and to address the social causes that gaverise to problems (Broom, 1995). This study showsthe need for both prevention and treatment and inthis the Health Department is an important player.The results show that publicly funded provision ofmedical treatment for victims of domestic violencein Western Australia is largely through emergencydepartments at public hospitals. These hospitals, bytheir very nature, reflect a treatment oriented,biomedical model of health (Shapiro, 1995; Spector,2004). As a consequence, there is a poor linkagebetween injury treatment and prevention of domes-tic violence, and between health services and grass-roots agencies that have service models emphasisingvictim empowerment and choice. In short, the lackof fit is not just between mainstreamed healthservices and grass-roots specialist organisations.There is also a lack of fit between injury treatmentand prevention and between service models, asevidenced in the following quote.

The health system is one which is based on veryclear step-by-step protocols y. So if the personcomes in with X wrong with them, then you do Ythen you refer to P and they have two Zed’s doneto them and then they get an X and take it homeand, and it’s not like that with domestic violencey even if there is a disclosure, even if there is avery obvious series of injuries and a history anddisclosure about violence from victims, they havea choice about what they want to do about it and

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while it may seem obvious to a person they’redisclosing to, that they should do this or do thatand do it immediately, that may not be thatperson’s choice. So there is still a whole amountof work to be done across the health systemabout that area of choice. (Health Departmentstaff member)

Even so, there are ‘pockets’ within the healthsector that attempt to address domestic violence.One respondent described a good example of suchinitiatives:

We have representatives [domestic violence liai-son officers] within our two [women’s andchildren’s] hospitals. They have meetings bian-nually in Perth where they then get together withall the other hospital liaison people from aroundthe state and they update each other y on thingsthat are happening. We also have had meetingswith the Department for Community Develop-ment with their FDVU around policies andresponses to domestic violence. We’re currentlyin the throes of actually putting together aproject around that specific task within thehospital. So hopefully that will sort of happenat that level. (Health Department staff member)

Initiatives of this type are ad hoc and notgoverned by directive or policy. It is also probablynot surprising that women’s and children’s healthservices lead health policy and practice in relation todomestic violence. It does highlight the importanceof a special focus on women’s health and reflects avoluminous literature about the impact of preg-nancy on increased levels of domestic violence(Frost, 1999; Grossman, 2004; Lutz, 2005; Martin,2004; Taft, Watson, & Lee, 2004). Additionally,worldwide, children’s health nurses have been at theforefront of screening measures and other interven-tions in the issue of domestic violence (see forexample, Frost, 1999; Henderson, 2001; Olds,Robinson, Petitt, & Luckey, 2004).

Having health professionals respond to domesticviolence in line with broader policy has, however,been less promising in the general tertiary healthsector. A 1998 Health Department initiative pro-vided financial incentives to publicly funded hospi-tals to assist them to develop and implementprotocols for intervention in, and management of,domestic violence. This scheme, however, is neithermandatory nor governed by policy or directive. Theuptake rate of the initiative has been poor to date:

My role is to actually go around or to contacthospitals and ask them would they like to set uppolicies and protocols for which we give them atwo thousand dollar incentive grant y there aresome twenty-four hospitals across the State whoin, in the last five or six years have actually takenup that offer. We have eighty-four hospitalsacross the State, so there is still a lot to go.(Health Department staff member)

This highlights the importance of demonstratinga commitment to policy by providing the necessaryresources for change. This commitment couldinclude, but is not limited to, a commitment torestructuring health services and staff training toreflect the changed policy environment within whichthey operate (Hill, 2002; Thurston & Eisener, 2006).

Conclusions

Given the poor health outcomes for women whohave been victims of domestic violence and theHealth Department’s fitful commitment to addres-sing the issue in policy documents, it is evident fromfindings of this study that two issues need to beaddressed. Firstly, there needs to be a commitmentthat extends beyond rhetoric to address domesticviolence in terms of its health dimensions (Thurston& Eisener, forthcoming). Secondly, to be effective,the health sector must collaborate with the networkof services and responses from other sectors throughthe forging and fostering of effective links (Howlett& Ramesh, 1995; Pal, 2001) between the domesticviolence community and the health policy commu-nity in Western Australia as well as internally. Thecreation of a special health department unit couldbe a first step facilitating communication, as peoplefrom other departments and from grass rootsorganisations have an identifiable ally with whomto work. Both the grassroots and professionalsectors have their own assumptions and languagethrough which knowledge is imparted (Kleinman,1980). Messages from different sectors often clash,complicating decision-making and action (Bacchi,1999; Frankish, Kwan, Ratner, Wharf Higgins, &Larsen, 2002; Scott et al., 2002). It is a challenge forall, however, to ‘tame the beast’ and strategies forimproving the health sector response must beconcerned with effective collaboration and partner-ship to obtain what has been called the collaborativeadvantage (Huxham & Vangen, 2005). Conflictsmay be inevitable as different policy networks come

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together (Bacchi, 1999); however, conflict can beproductive (Scott et al., 2002) if managed with acommon goal to put an end to the abuse of womenin their homes.

Acknowledgements

The authors wish to acknowledge the CanadianInstitutes of Health who provided funding for theundertaking of this research.

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