Relevance
The PRECODE study will combine quantitative and qualitative methods to explore and explain the dynamics of DVA referrals before and during the COVID-19 epidemic in the UK. We will be focusing on new evidence gaps created by the uncertainty about how general practices responded to (live) online DVA training and how they adapted their consultation methods in relation to DVA in the context of the COVID-19 pandemic. The importance of filling these gaps is driven by the prevalence of DVA globally and the UK [
5,
13,
14,
34] with numbers likely to increase in the coming year(s), requiring an effective response from the NHS, particularly general practice.
The imposing of severe lockdown measures during the COVID-19 pandemic led to closure of face-to-face DVA services and consequential reduction in DVA referrals in the UK (despite increased DVA prevalence). Evidence-based, continual and effective remote support of DVA survivors and referrals to DVA service providers is crucial, as it is likely that even when social distancing is relaxed, a smaller proportion of general practice consultations will be face-to-face [
54]. Analysing the change in referrals and the adaptation of clinical responses to DVA during the pandemic is crucial in underpinning future planning, and this is the first mixed-method study to do this on a national scale using qualitative interviews and over four years of referrals time series data.
Strengths and limitations
Key strengths of our study design are the rapid mixed method synthesis of diverse evidence sources. Both the quantitative and qualitative methodologies of the study are well-established and widely used technical frameworks. The mixed method approach will allow for a broader and more granular exploration of the primary care response to DVA during the pandemic than quantitative or qualitative methods alone. The triangulation of quantitative and qualitative findings using rapid analysis and synthesis methods successfully applied previously in the context of COVID-19 research [
55,
56], will allow for a rapid assessment of the variation, relevance, feasibility, and safety of primary care responses to DVA before and during the pandemic and its aftermath.
Further strength lies in the multi-professional/multi-agency collaborative approach linking general practice to the DVA sector. The study team members have led the field of domestic violence and health research in the UK for almost two decades, combining quantitative (epidemiological studies, trials, surveys, economic analyses) with qualitative methods (cross-sectional and longitudinal interview and ethnographic studies) and systematic co-production of research with third sector partners. Team members have diverse expertise around the development, delivery and testing of DVA interventions. Our landmark IRIS trial is the basis of a nationally commissioned training and advocacy programme linking general practice to the DVA sector. Team members work to improve and promote the healthcare response to DVA in the UK and internationally, work in strong partnership with service users, the DVA sector, including close collaboration with IRISi, and the RCGP, and they seek opportunities to disseminate findings internationally and to influence UK policy. Team members also lead evidence-based innovation in the health care response to DVA and are committed to influencing system change within health services and the DVA sector.
The study team will actively involve three service user expert groups. Throughout they will provide valuable insights into the perspectives and experiences of survivors. Finally, the study will benefit from including the views of different professional groups with expertise and experience in DVA and without a specific role in this area.
There are three possible limitations to this study. The first limitation concerns the possible generalisability and transferability of the findings to non-IRIS practices. Although we will ensure the diversity of recruited practices in terms of size, location and population, as well as the diversity of research participants, as the study is focusing on the pandemic responses of IRIS-trained general practices to affected patients, the findings will not necessarily be applicable or relevant to non-IRIS trained practices (consisting the majority of general practices in the UK). We will mitigate this by integrating our work with parallel research exploring the experiences of general practitioners with remote consultations in non-IRIS practices in the UK [
53]. This triangulation work will support the development of resources and guidance to all clinicians working in primary care, with or without IRIS specific training. These resources will be developed with input from primary health care stakeholders from both IRIS and non-IRIS practices to ensure their applicability and relevance.
The second limitation is potential participation bias: the views of general practice professionals participating in the interview study might reflect the narratives of those individuals who may have been more experienced in or more engaged with the management of DVA identification and referral or more favourably disposed to the IRIS programme. Equally, advocate educators participating in the interview study might reflect the views of a self-selected group of professionals experienced in delivering DVA training and support.
Finally, the lack of patient research participant voice within the study will limit the interpretation of findings. As a result, although the perspectives of professionals will give indication of some of the barriers that might prevent patients from disclosing DVA in general practice, and the study will be guided by the perspectives of PPI&E members, our findings will not fully explain why some people affected by DVA do not seek or accept professional support during the pandemic. We will endeavour to interpret our findings in the light of relevant academic and policy outputs exploring survivor experiences of the pandemic.
Implications for practice
Enabling services to respond effectively to DVA is a UK policy priority [
23,
57‐
59]. Our study will support the implementation of this policy by generating and disseminating mixed-method evidence about the primary care response to DVA during the COVID-19 pandemic. Our findings will inform primary care and DVA service responses in the UK and other countries implementing remote clinical consultations, as they re-configure during the pandemic and beyond, including the interface between DVA and the delivery of primary care, training, and support for patients identified by front-line practitioners. We will formulate specific recommendations to improve online training and guidance on how primary care clinicians can safely and effectively address DVA in remote consultations. The recommendations will consider the needs of both IRIS and non-IRIS trained practices and ways in which DVA training and resources can be relevant and more widely available to general practices across the UK.
Given the highly sensitive nature of DVA research, we will adopt trauma-informed dissemination and data sharing approaches, still consistent with open science [
60,
61]. Findings from our synthesis will directly inform policy on training and support for general practices by establishing bi-directional communication with policy makers, commissioners, health service providers, service users, and third sector organisations. As co-produced research with IRISi, the RCGP and PPI&E members, we will rapidly funnel evidence to support policy and practice nationally. Our evidence, resources and guidance will be open access and available to policymakers, commissioners, services, and front-line practitioners. We also expect to inform future national calls for evidence that feed into policy about DVA, local needs assessments and commissioning of both health and frontline DVA programmes and services.
As with other health inequalities and adversities during the pandemic, although DVA has been made more visible in the last year, the health and domestic abuse sectors are struggling globally to re-configure services and develop new strategies. The study will drive inter-sectoral UK policy with relevance globally, by contributing resources and guidance for primary care clinicians addressing DVA using remote consultations. These will be vital in supporting safe and effective care for affected patients as primary care re-formats post-pandemic.