 Good day everyone, welcome to this fourth webinar on family violence and COVID-19. My name is Harris Lizzy Dakis, I am the chief executive officer designate of the World Organization of Family Doctors, WONCA. And before we kick off our webinar, I would like just to overview with you the ways that you can interact during the session. So for those of you who attend the session on Zoom, you can see two buttons. The chat button will enable you to communicate with other panelists. And then we have the Q&A button that will open a new window through which you can ask questions and then our great team of monitors and the panelists will try to answer as many questions as possible. Please also consider following us on Facebook and a reminder that this registration, this recording will be available afterwards on Facebook, on YouTube and on Youku. Now it is my pleasure to introduce to you the chief executive officer of WONCA, Dr. Garth Manning. Thank you, Harris. A very warm welcome everyone to this, the fourth in a series of WONCA webinars. Today the topic is family violence and this is a critical topic to discuss at any time, but most especially in the time of pandemic and lockdown. I saw recent statistics for the UK which showed a 49% increase in calls to a national domestic abuse line and similar figures have been reported from other countries. Today, the co-chairs of WONCA's specialist group on family violence, Dr. Haggit Daskal Vaikhenler and Dr. Nina Kupchavar Buchek will lead the topic. Panelists include Professor Jean Fedder, Ms. Medina Johnson, Dr. Leo Pass, Professor Dr. Sajjar Uttman and Dr. Joy Mugambi and they'll be offering some practical tools and advice to family doctors about how to manage family violence. As Harris has said, we'll be monitoring your questions and comments and Dr. Anastav Dao will be bringing many of those together to submit to the experts. But before all of that, I'd first like to hand over to our WONCA president, Dr. Donald Lee, for his introductory remarks. Donald. Good day, good morning, good afternoon, good evening. Welcome to the fourth WONCA webinar. Family doctors around the world continue to rise to the challenge of this awful pandemic. We are working closely with our public health colleagues, our specialist colleagues and all healthcare workers. In the midst of this massively increasing workload for family doctors, I'm proud of the level of support and collegiality displayed within and across our member organizations and from region to region. Family doctors all around the world are disseminating scientific advice, clinical updates, reflective messages and professional support through their social media links and connections. They are keeping in touch with each other regularly, like family members, relaying information, urging courage in these extraordinary times. The WONCA webinar is also a platform for all of you to share experiences and offer mutual support. Tonight members of our special interest group on family violence and invited colleagues will consider some special challenges experienced by family doctors as COVID-19 affects everybody's well-being and daily lives. Some of the risk factors of family violence greatly increased by the lockdown, economic crisis and social isolation of the epidemic and moreover the availability of specialized services and ways of assessing them have changed significantly. Our presenters will give us an overview of family violence, highlighting aspects related to the pandemic and offer practical tools useful to family doctors in daily practice as well as in the current situation. So with this, may I hand back to Graf and then we can start the webinar. Great. Thank you very much Donald and I'll hand straight over to Haggit and Naina to co-lead this session. So over to the two of you. Thank you very much. The slides please. Thank you. Good afternoon. First of all, on behalf of our special interest group, we would like to thank Dr. Wonka, Dr. Lee, Dr. Manning, Dr. Stadwell and Dr. Ligidakis for inviting us and enabling the webinar. Next, please. Our objectives in the webinar today are to give a short overview of family violence, highlighting what is happening during the current COVID crisis and specifically to talk about and demonstrate our role as physicians. Next, please. Okay. We will next please, Harris. Okay. There are many subgroups of abuse within families and sometimes there may be more than one victim and more than one abuser. There is significant overlap in clinical sequela and principles of care. The major part of today's presentation will focus on intimate partner violence, but it is important to remember that there are also other victims. Next, please. As a start, we would like to ask your participation answering the following question regarding prevalence of physical or sexual violence towards women. So please open the poll button that you have underneath and answer the question. We will give a few seconds for that. Do we have results already? Okay. Very good. So next slide, please. Let's see the data. Family violence is a global phenomenon related to gender-based violence and to our society's culture. According to the WHO, one in three women throughout the world will experience physical violence by a partner or sexual violence during her lifetime. It is one of the leading causes of death for women. A partner is responsible in almost 40% of homicides involving a female victim. Only around 50 years ago, the first shelter for battered women was opened. Our society has still a lot to do to mitigate this major public health problem, which is actually an epidemic that is here long before the coronavirus one. Next, please. But it is important to show and acknowledge that men can also be victims of intimate partner violence, though we know that the impacts for them are significantly lower. Child abuse, sexual abuse, and elder abuse are all common and of epidemic proportions as well. Next, please. So what are we talking about? Neglect is included in the spectrum of violence. It affects children or other incapacitated people, and it may be physical or emotional. Physical and sexual abuse are common and do not need too much explanation, but it is important to understand also what psychological abuse is and the range of controlling behaviors which underlie intimate partner violence. Next, please. Here we can see examples of controlling behaviors versus equality-based behaviors. As you can see, coercion and threats are used instead of negotiation and fairness, economic abuse versus partnership, using and manipulating children versus responsible parenting, isolating the spouse as opposed to allowing supportive relationships. Once we understand that control is at the basis of intimate partner violence, we can understand also neotypes of abuse and control that appear, for example, during the current crisis as shall be demonstrated. Next, please. Every physician should know the clinical presentations with which victims might present. These should be regarded as red flags, prompting us to include the possibility of abuser neglect in the differential diagnosis. Common clinical presentations can be general indicators, such as delayed medical treatment, medical visits or eye contact, as well as a partner who won't let the patient be alone with the doctor. Physical health indicators include injuries or their sequela, chronic pain syndromes, uncontrolled chronic disease, infections and many more. In the area of OBGYN, unsafe sex, unwanted pregnancies, abortions and complications, maternal and fetal problems, STDs and more. Physical health presentations are very common and it is recommended to ask appropriately about past or current abuse when we see patients with any of these, for example PTSD, depression and anxiety, eating disorders, substance use and suicidality. Due to our limited time, we can't discuss now clinical presentations of perpetrator, but I do want to emphasize that though the vast majority of violence occurs because of societal norms, in some cases, violent behavior may stem from medical problems, a brain lesion, dementia or uncontrolled psychiatric disease. When violence happens because of a disease, effective treatment must involve the medical system. So it's our job as physicians whenever the perpetrator is in our care to identify whether there is an underlying disease causing a change in behavior. This should be done without compromising the victim's confidentiality course. Finally, many abused people will have limited access to available help, but others are frequent users of the health care system. So any contact with the health care system is a window of opportunity to diagnose abuse or neglect and offer help. This is even more important now during the pandemic. Next please. I'm now handing over to Naina, my co-chair, Naina from Slovenia will talk specifically about the aspects related to the pandemic. Thank you. Thank you, Hagit. It has been a pleasure to co-chair the special interest group with Hagit since November of 2019. So like COVID-19, catastrophes usually provoke family violence. By deprivation, challenges in implementing isolation and self-protection by poor living conditions and lack of food. The level of stress, fear and anxiety is increased by homeschooling and care for the children, by unemployment, financial strain, family separation and some government measures. With difficult access to community services, the amnesty of prisoners and the institutionalization of mental patients in some countries is somewhat worrying. Leading the access to help even further are the lockdown, curfew, shutdown of public transportation, closure of state and regional borders, services and help moved from the personal contacts to online, age, disability, lack of skills and no access to a communication device may all disrupt the continuity of care. The robust data is still lacking, but many countries report significant increase in detection of family violence, up to seven fold in official reports. More calls to help lines and also higher famicide rates compared to equivalent period in 2019. Can we have the next slide, please? Controversially, a decrease in calls and demand for help is also alarming, suggesting the access to help may be blocked by the perpetrators. Next, please. The survivors of family violence can feel really helpless and even apathic by the limited access to services during the COVID. They might consider their situation to be minor, unimportant and hesitate to add to the burden of the healthcare services. Due to self-isolation, quarantine and hospitalization of one or more adult or competent parents, the care of the dependent family member has often been left in the hands of an incompetent or even violent family member. The COVID-19 pandemic has presented new forms of abuse, such as, quote, throwing the victim out of the apartment if they cough one more time. On the other side, the infected perpetrator may threat to purposefully infect other family members. Next, please. Recognizing family violence during the pandemic period can be more challenging as it demands additional technical and communicating skills to manage telemedicine. The clinical signs and symptoms of exposure to family violence may be mistakenly interpreted as the so-called COVID anxiety. Family violence can therefore remain underestimated and unrecognized. No doubt, our workload during the pandemic has been increased and may be even challenged by our intimate home situation. Understand points, beliefs and possible exposure of family violence do play an important role in our work. Next, please. An example of extreme family violence in healthcare workers has been reported in Sicily, Italy. A 20-year-old medical doctor has been killed by her partner under the accusation that she had infected him with COVID. Next, please. Outside the health center, the new online services have been established and the existing ones were increased. Police in some countries publicly reassures the population of their continuous service, regardless of the crisis. Increases in shelter capacity have been provided for additional accommodation. Help can be of big benefit. Interdisciplinary collaboration is definitely a goal worth the effort and maybe not reached yet everywhere. Innovative entry posts for seeking help in cases of family violence have been introduced. Masqueria initiative in Spain makes it possible to signal violence in the pharmacy by using a code word. Non-verbal messages has to be distributed continuously and cautiously and in very selective manner to target the victims only and preferably not the perpetrators. Wearing or displaying a garment of a certain color or object are additional possibilities to signal. Different public campaigns in several countries have helped enormously to raise awareness about the increase in family violence during the COVID-19. And here is a question for the participant. Can we see it, please? We are very curious where you come from. So I will give you a few seconds to mark which continent you come from. Please vote, if you will. OK, I think this has been 10 seconds. It should be enough. Do we have any answers? OK, very interesting. We see that the majority of participants, a little less than half is from Europe, but good representation of all the continents, Australia, Asia, South America, North America, and Africa. Thank you so much for bearing with me. And I gave my words to Professor Jean Feodor. Jean, thank you. Thank you for that. And if we now turn to the first slide here, just introduce myself. I'm a family physician for many decades and work as a fine physician in Bristol, a small provincial town in Britain, in England. I've also led a research group around domestic violence now again for a couple of decades, with a particular focus on trying to get an appropriate and safe health care response. I also work with colleagues in other countries in the occupied Palestinian territories, Brazil, Nepal and Sri Lanka, to do the same. And the work focus is particularly on the primary care family medicine response. Medina, can you introduce yourself? This is a double back by the way, guys. Thank you, Jean. Hello, everybody. My name is Medina Johnson, and I'm Chief Executive of IRSI. We are a small social enterprise established to promote and improve the health care response to gender violence. And we lead on working with partner organisations to promote our advocacy and training programme in primary care. So we work with just over 10% of all general practices in England and Wales. And since the programme has been live, our partners have supported over 15,000 women who've been referred by their primary care physician into direct specialist support from a gender-based violence service. And I've been working in the sector for about 15 years now, about 12 of those alongside Jean. Thanks, Medina. Let's have the next slide. This is a slide to help us orient our discussion a bit. So if you could answer this question about whether within your country there are some specific domestic violence, partner violence or family violence services that you can refer patients to. There could be NGOs, there could be government, local government services. We're interested to know how many of you have access to those services for your patients. Right, Harris, do we have enough to be getting on with, you think? OK, so if we could have the next slide. The majority of you do have access to the service, which is a good thing, obviously from many points of view. It's a good thing from the point of view of this presentation, because what Medina and I are going to focus on is a way of responding to patients which is dependent on there being some service that can support them and that you can refer to. Now, there are parts of the world, particularly low income countries, where there just isn't that support available. The WHO has produced a really excellent clinical handbook focused on particularly primary but also sectional reproductive health services for how to respond to partner violence, even if you don't have specialist support around you. And so I hope what we're going to do is of interest to you as well, but for specific guidance on what to do in terms of containing and responding, I would recommend the WHO handbook and we will be giving links to these resources. But what we're going to focus on now is a reaching out to patients when there is that possibility of recommending further support. And if we could have the next slide, Harris, what we're going to be focusing on is actually carry on. I thought the animations had all the animations work. Harris, you said the animations weren't going to work, but they work perfectly well. The consultation is something that all of us family physicians understand is our key tool, probably more than blood tests or any X-rays. It's that consultation which allows us to orient ourselves to the patient's problem and to respond appropriately, diagnostically and in terms of management. It should be, in relation to family violence, a safe place, maybe the only safe place for disclosure of abuse or violence. And as we know, doctors are still a trusted group of professionals who are able to get that disclosure. The challenge for us under the pandemic is how do we still make that consultation a relatively safe space and that gives access to services and support. And we're going to try to illustrate this through a role play between me and Medina. So I'm going to be the doctor, she's going to be the patient and I'd be grateful if my fellow panelists could turn off their video so that all you see is me and Medina having a conversation. Although we're going to take on new roles. Good afternoon. This is Dr. Meadowsweet returning a call from Bella Oakfield earlier today. Hi, yes, it's me, it's Bella. Thank you for bringing me back. How can I help you, Bella? Well, since yesterday I've become quite weazy and it kept me up last night. Oh, do you have a cough? Yeah, I do, but then I usually do. And what about shortness of breath? Yes, when I'm weazy, but not when I use my inhaler. And which inhaler do you mean, Bella? The blue one, the Ventolin. OK, and do you have a fever? No. And do you feel generally unwell, achy or in some other way unwell? No, not really, no. And what about other symptoms like stomach pain, loss of taste, loss of smell? No, no, nothing like that, no. OK, well, that's good. Do you still have your peak flow meter? I do, yes. And I've wondered whether you'd ask me about that. Am I reading today's four hundred? All right, that's that's a bit lower than usual, isn't it? Have you been using your brown inhaler? Actually, no, I haven't. I stopped because I was feeling well and I don't have one in the house at the moment. OK, Bella, I think it's probably time to start using it again. And I will send the prescription to your pharmacy now electronically and you'll be able to pick it up there. So please use two cups twice a day and use your spacer. If your peak flow drops below three fifty or if your wheeze and shortness of breath becomes any worse, please ring us immediately. OK, thank you, we'll do, thanks. Um, how are you doing generally, Bella, in this strange world that we're all now in? Yeah, it's hard. Can I just check whether it's safe for you to talk without being overheard? Please just reply yes or no. Yes. OK, are you alone in the room? I am, yes. OK. OK, Bella, in what way are you finding it hard? Well, you know, Steve and I were having some problems. Well, I knew that you were having some arguments. Yeah, it's a bit worse than that now. So since lockdown, he's monitoring, trying to control everything I do. I can talk now because he's gone for a run with both at home all the time right now, because our jobs have stopped, which is hard. He gets really angry a lot, shouts a lot, blames me for everything, says I'm useless. Then blames me because he's getting angry because I'm useless and just goes on. Oh, I'm sorry to hear that. It's not your fault, Bella, and to blame you is just wrong. This must be really difficult for you, particularly with your two boys at home. Yeah, I mean, they seem like they get frightened. They take themselves up to their room. They disappear when he gets angry and when he shouts. Bella, are you are you afraid of Steve? Are you afraid of him? Not usually. He did get really angry at the weekend. He pushed me against the table. I'm all right, he apologised, but I was a bit scared at what he might do next. That's a really difficult situation. Are you able to reach out and talk to any of your friends or your family about what's happening to you? Well, mum and dad are self-isolating and they're quite elderly and I don't want to worry them. I see my friend Julie, we have a chat at the shops, which is great. You know, it's nice to know she's there, but she can't actually do anything. You know, I hear her voice, which is nice. Bella, are you feeling unsafe? Not unsafe. I feel trapped. But I don't think he's really going to hurt me. I just feel very jumpy all the time on edge. Just coming back to your children, to the boys, remind me how old they are. John's eight and Peter's ten. You said they're frightened by Steve shouting. How are they otherwise? Yeah, I think they're OK. As I say, we're we're trying to school them from home. Steve helps with the schooling and the boys really like that. We go for walks as a family. I think, yeah, I think they're coping OK. You know, it's it's difficult and they see that, but they're OK. Are you worried that Steve may hurt them? No, no, absolutely not. He wouldn't do that. He adores them. OK, Bella, I think you're going to need some help with the abuse you're getting from Steve. I wouldn't call it abuse. But I'd like to do is to refer you to a support worker who has lots of experience working with women who are in this kind of situation. You're not alone in this at all. She'll be able to give you immediate support on the phone or by Skype and work out with you how you and the children can remain safe. I'm not really sure I need that at the moment. Well, I think you do. But I won't act on that unless you agree. If you do, there's still the challenge of when to speak to her in confidence, unless there's a day in time when you're sure that Steve is out out of the house. All right, OK, I think I need to think about that a bit. I understood. I understand that. If it's OK with you, I'd like to talk again. Is there a time tomorrow that would be safe? Well, he'll go for a run again. I'm never quite sure what that time is. Usually usually afternoon, but there's no fixed time. Understood. When he does go out, please ring the practice and ask the put through to me. I will let the reception know that you'll be doing that. If I'm talking to another patient, I will ring them and I'll bring you back as soon as I can. Sorry, I'll ring that other patient back and I will talk to you immediately. Are you really sure that's necessary? Sounds a bit. Sounds a lot. Is that necessary? I am sure. And I'd also like to give you the direct number of Mary, the support worker. I would like to refer you to if before we talk again, you want to contact her directly without talking to me, please do. OK, all right. Thanks ever so much. I'm sorry to be such a pain. You're not a pain, Bella. You're in a painful situation and this is part of my job. Take care. Right, Harris, we'll de-roll now and go back to the to the next slide. Medina, you're going to talk about this. Sure. Thank you. So what Jean and I thought we'd do now is just and pick and talk through some of the things that you heard us voicing in the role play. And we're going to do that by showing you some guidance that we've put together over the last few weeks, which has been in response to some of the clinicians that we work with in the Irish programmes in the UK, but also in response to a general feeling from clinicians and colleagues who've been asking for some support, managing gender violence and family violence, particularly in the remote consultation context. So we've developed this guidance, whether or not clinicians have had specific training around family violence. And we're going to talk you through each of the sections. There are four or so sections. This isn't us telling you the best way of doing things. It's us sharing with you what we've found helpful and what we suggest is helpful. And the full version of this is on our website, which we'll share with you at the end of the session. And really, please just take and modify anything that you find useful for within your local context. As we say, it won't translate directly, but hopefully there'll be some useful pointers and prompts that you can take and localize. Next slide, please. So if we don't ask, our patients are not going to disclose. That's been our experience over many years of doing work in this area. And asking is part of the consultation. As you could see in my consultation with Bella, or Dr. Meadowsweet's consultation, it wasn't the first time I asked. It was something I definitely wanted to ask before the end of the consultation, because I had some prior knowledge that things were going to be difficult at home. Some situations you may not know the patient, or you may not have prior knowledge, and then you use your judgment, I think, about whether you ask that. I think in the current pandemic, probably asking all patients, and most of my consultations are now by video or audio, how things are going, is probably a good thing. And I'm not talking about screening. I'm just talking about checking how every patient is somewhere in the consultation. And this is how one can potentially do it safely, because there's a risk of being overheard and for an exacerbating the violence. I think checking on immediate danger, most of our patients are not going to be in immediate danger. Either now, in the pandemic and before, but it's part of our duty of care to ask that. And the use of some close questions where the answer can be yes or no, without giving away the content is an absolute benchmark, I think, for asking about risk and about safety. Next slide, please. So we thought it important to discuss what we mean by a response and how the clinician is going to respond. So we thought it important to discuss what we mean by a response and how the clinician can validate the patient's experiences and the response to the ask questions. And I think the key thing here is to keep things really simple. Don't overthink it. When we're training our clinical colleagues, this is often a stumbling block. And we're not asking for the people to solve the problem to cure what's going on for the patient, but to validate that they've heard and that they understand what the patient has reflected in her disclosure. So something very simple, like I believe you this isn't your fault is very securing and validating for someone who perhaps has never had anyone say that to them before, perhaps because they've never disclosed before, or when they have disclosed, perhaps the response hasn't been helpful. So a very simple, clear, direct validating message to show that the patient has been heard is very helpful. In terms of the support that the patient might need, again, not trying to solve or fix, but offering a signpost into some appropriate support, which we'll come onto in a moment. Next slide, please. So we don't expect clinicians, frontline clinicians to do full risk assessments. That's not within our competence, but we do need to ask about some signs of potential increased risk and particularly asking whether the abuse is escalating is getting worse. And there was some indication of that in the consultation with Bella that actually things were getting worse. And that's like a red flag, which we need to pay attention to. And there's again this issue about, you know, is it safe for this patient to remain in the home where the abuse is escalating. And that does require some judgment on your part. And I think it's important to be that you can't make that judgment in one consultation. It means possibly that you have to keep on asking and thinking about it in subsequent consultations. It's risk assessing. It's not a full risk assessment. And next slide, please. You heard Dr. Meadowsweet ask Bella some direct questions about the children. And perhaps we'll pick some of those up in the panel questions at the end. I think it's important to ask the people in the household. Perhaps there are vulnerable adults, older vulnerable patient people in the household. So it's very important to also ask who else is there in the house, as well as the immediate family. It's also important as you heard Dr. Meadowsweet check when is a good and a safe time to call. And that closed questioning of just say yes or no. And providing an open time when the patient can be called back is really, really helpful. Offering a referral is essential. And it's important to remember that an offer of referral doesn't always mean that the offer will be taken up. It can be hard as clinicians to hold that, to then sit with that if a patient says actually right now, no, I don't want to direct referral. But we always come back to the patient being the best assessor of her risk. So sometimes we have to sit with knowing that we've offered a referral that hasn't been taken up. But also knowing that by offering that referral, we've created a pathway in an opening should the patient want to come back and seek further support. And also by signposting to helplines and perhaps online support can be a really useful next step. Next slide please. Okay. And we're aware by the way that country to country, there's variation in what you require to do. And there's some countries where there is a requirement for mandatory reporting, both of domestic violence, but also if there are children in the home. So we're not suggesting you do anything different from your current country wide guidance. This is sort of UK orientation we're giving it. But if one can help protect the agency of the patient and making decisions, we feel that that's really a priority. Because when you're experiencing partner violence, your agency is stripped away from you. You're being coerced. And we tried to not replicate that in the way the state or family medicine engages with the survivors. So that's an important sort of debating point really recording is crucial for medical legal reasons, but also for communicating to your other colleagues who may then have contact with the patient in the UK. We now have electronic medical records in general practice and there is a move towards which has been enacted patients having online access. This is potentially a tool for coercive control of a partner or coercive family member. So it's really important if you do record a disclosure that you make sure that that is safe and not accessible by the partner. We also think that it's important to code family violence in the records of anyone else who might be vulnerable and that includes children, but also vulnerable adults. Adults would say learning difficulties. That must also be in their record. We also would encourage you to record if you have a concern, not a diagnosis, just a concern, because that needs to be again for your benefit and for the benefit of your colleagues. Next slide please. So just to end here on the sort of working out some of the implications of this guidance and trying to reflect on the role play you saw. If your practice has a website, the patient's access say for making appointments or getting information, we would really encourage putting information about family violence and how to access support on that website. This is an example from a practice in Bristol which has it on their homepage on the left and on the right if you click on that you find information about domestic violence and about also numbers you can ring independently of disclosing to the doctor. And it's part of this trying to make relevant information as accessible to our patients as possible. Thank you very much. And I think it's now my honor to introduce Leo. I don't need to introduce him, I'll introduce himself. Who's going to take us into some of the other implications of the family medicine response. Thank you, Jean. I think you saw a beautiful example of what can be done in a country where you actually have a lot of facilities like in the United Kingdom. When I started my training 40 years ago I was not aware at all and in fact I'm now an old general practitioner trying to retire. I'm still working in the University of Leuven Psychosocial Care and I want to share with you a number of simple issues which allow me to remember what I need to do in my practice. I'm the proud father of a family with three children and the motto of my wife was a family is a gift for life. And it was only 20 years ago that I really became aware of the fact that family violence was a very important issue due to a political situation in our country with child abuse which was very upsetting the people. So I started writing to Wonka, I started meeting colleagues, meeting on conferences and finally the network of Wonka Special Interest Group was created. I draw your attention to the email which is down on the right corner of this slide because we now start a project to allow people to share what is being done. What you have seen in the example of Cine and Medina is actually what can be done in a country when there are lots of facilities but many countries do not have these facilities and we want to share how these different techniques can be shared in different contexts. Next slide please. The good message is actually that our professional role doesn't change. It's whenever you go any country, any continent, you'll actually see that psychosocial care is very central in general practice. It doesn't change either due to the COVID crisis. What changes actually is the way we communicate and we have some problems to communicate well. So one of these aspects we must be aware of that we are a doctor very often of a whole family. We must be aware of the different perspectives of all the patients in the family even if we have only one person online. But having this person online and having secured that she or he can speak we can ask them about also the beliefs of the other members and how they are coping with the actual situation. But we have to adapt to the context in our country. The facilities Jean and Medina actually indicated like domestic violence advocated in practice or special services may or may not be present in your situation. And in fact the context situation of the clients may be very, very different. It's different when you are isolated in drinking more. It's different when you are pregnant. It's different when you are actually considering leaving your husband due to quarreling and not being able to cope anymore with the relationship and when you are actually forced to stay together. What I do as a general practitioner is actually remember that I must not make five mistakes which I made very long time ago. I actually didn't ask I didn't access I didn't assess the context the risks of the people. I didn't really agree but I gave advice and what we must do is actually ensuring follow up as well. Very clearly Gene had a sign of this Bella that there was a worrying situation in the past. I think that during this Covid crisis we must wonder about our patients who earlier disclosed some problematic situations at home. I want to share with you the story of a man of 30 who came to my office actually he was a past addict and he actually declared that he stopped drinking and stopped using weed and he was very happy to have a child. In fact he was worried because his wife was neglecting the children and bullying him on her turn. So actually the perpetrator who admitted that he was actually jealous and very aggressively actually was now in the situation being the victim. What helped him was actually thinking about that his wife actually was loving the children while neglecting and what helped him was also the fact that thinking about time to be with the children time to be with his wife and time to have for his own actually helped him to cope with the situation and in fact I could affirm to a special office but he was not willing to ask to talk about all his problems but it helped him actually to focus on the relationship and not bullying not being jealous and taking the children as the prime motor for a new relationship. So the message of hope I want to give is that solution-focused approach helps next slide and this is actually the essential message I want to provide to you. When we are in training in the past we have been acting on bodily feelings mainly but what actually is the concern of the people is much broader than that. We must be able during our consultation to analyze and assess what happens in a family the mother who contacts us being tired might be a COVID-19 patient but it might also be that she's thinking about her husband who lost his job or being afraid that he actually starts drinking or that she can't cope with the boy who's actually imitating the example of his father. So when we actually assess the situation we must always keep in mind that we actually assess what's the person we are talking about is thinking how he feels or she feels and what actually would help actually to cope with these situations. Next slide please so our professional role didn't change during the COVID-19 we must be actually proactive always when we are worried about the situation and family violence is often presented as fake complaints we must actually work also to overcome our own fair to ask about these things and we must accept that we cannot solve the situation on our own we must also accept that people actually may be ambivalent to do or not to do what we think would be a good advice. We must leave the autonomy to the patients do not forget to ask at the start to talk. There are difficulties in actually security online but there are also limits in confidentiality. If you think that there is an urgent situation you may act because of vital needs. At this moment the police actually has special orders in our country to be able to actually avoid conflicts at home by separating couples if needed even without going through the judge. But be very clear about your own limited possibilities and it's very important to agree common goals. How can I help you? What can you do yourself? And finally next slide be aware that we are actually part of a trust community network. It's very important to realize that families being in isolation have very much more difficulty to contact each other but you can ask to the client online if there is any person she can trust with whom she can actually agree with a code if there is a danger. Also we are not alone and we are due to actually inform ourselves in our practice about the new regulations which are available due to this new crisis situation. So please get in contact with your fellow colleagues in other services to know what are actually at this moment the new measures to be taken to actually put people into contact. Thank you so much. So now we will introduce Sajjar from Malaysia. Please. Hello everyone. Sajjar slide Harry please. Thank you very much. Let me please introduce myself. My name is Dr. Sajjar Oatman. I'm from the Department of Primary Care Faculty of Medicine University of Leia. I am also the chair of the Violence Intervention Committee University of Leia Medical Center where we promote and we train healthcare providers in managing interpersonal violence and also family medicine specialist in Malaysia. So what I'm going to present would be regarding the children, older people and also other dependent people in the same household. Can I have the next slide please? Children, older people and individual with disability are also vulnerable to family violence. To complicate the matter, they may have issues of mobility and cognitive ability. They may also have problems to express their fears and experiences and the impact of abuse can be amplified where minor injuries can cause serious harm and permanent damage. So especially during pandemic, caregiver may not be able to take effective care of their dependence. The economic crisis may cause hardship such as difficulty in getting an eye or enough money for medications and many other basic needs. In such situations, neglect of those under their care can happen either occurring on purpose or otherwise. In addition, the caregiver can get infected in which they will be quarantined or also the caregiver can succumb to the disease. So in this situation, this could lead to issues of protection and psychosocial needs for those under their care. And during the crisis and increased parental or caregiver anxieties and frustrations might lead to an increase in violence or neglect among those under their care. In current, older people and individuals with disability can face problems to assess health or other support services as they may have limited or no access to communication technology and a reduced cognitive ability or mobility can make the situation more challenging. So what do we do? Can I have the next slide please? In general intervention for children, older people and individuals with disability require coordinated and system integrated approach. It is very challenging. So what can general practitioners do? Firstly, you can provide parents or caregivers with skills to manage their anxieties. In addition, you can help them to cope with the demand of caring others. You can develop specific messages to family members healthcare providers and caregivers to explain the risks for abuse and neglect among children older people and individuals with disability. So provide ways to care for this group of people at home. And what can you do during clinical consultation? During clinical consultation it is best to have a high index of suspicion of abuse or neglect that may occur among other family members. This can be done based on clinical observation including the dynamics between caregiver and the patient. On the other hand one may observe that there are less face-to-face encounters for this group of people such as clinic visits or for day care centres or during home visits. So in such a situation an active case finding or some sort of surveillance visit can be done to explore the possibility of abuse and neglect. Particularly among primary care team seeing patients throughout the crisis. I think importantly that you know the local legislation of safeguarding the children, older people and people with disability please know whether there is any mandatory reporting law or healthcare providers to report suspicion or confirmed case of abuse or neglect. And last but not least make sure you know local resources such as shelters, telephone hotlines to assist referrals for support of these people. It is important that the psychosocial support should also include support at practical level to survive the current challenging situation. So what I can sum up is that please remember there are also other family members in the same household who are also vulnerable for abuse and the intervention is complicated and it needs your high index of suspicion and intention to intervene the abuse. With that I will pass to Dr. Joy Mugambi for the next slide. Thank you. Thank you very much. My name is Dr. Mugambi Joy. I'm a family physician from Kenya and Secretary Wonka Africa. I also am part of the special interest group in terms of family violence and glad to be here today to share a bit about the low-medium income countries. What they are about sexual and gender-based violence, the challenges that we are facing as low-medium income countries. Next slide, please. So basically, we have a lot of living disparities in the low-medium income countries. At your top left you see a very beautiful house with a swimming pool and all set up. Most of the intervention set out in terms of call centers and toll-free lines have been set up for such a setup because here they have access to security, they have also access to mobile phones and can easily interact and be able to call when they need to. They have also access to insurance and can easily call an ambulance and be accessible to get care whenever they need. In these same homes they have access to nine-years. Their children are well cared for in an enclosed place. So security is ensured for most of their children at the same time. At the top left, yes, domestic violence does exist. They have broken families which are going through a lot and they are the same homes that have access to television to internet access where pornography and stuff that can ignite family violence and sexual violence in most of these homes. So in other instances we have the top left where we have our whole area of flats which we call the informal settlements in these homes they have smaller spaces they have no access to play areas for the children they have enclosures and these are the same people who run the economies of most countries in the low and medium income countries and these are the same homes that someone is being told to stay at home and work at home so it becomes also difficult. The same homes have inadequate access to insurance so ambulances will not respond in most low and medium income countries because cost curfews as we will discuss later have hindered that access. These homes, yes, have access to homes the good thing we would say in my country is that we have access to what we call the Nimbakuni initiative this is an initiative that allows each 10 homes to have a leader who you can communicate too easily and they can easily help you access healthcare and be able to get to a facility or to be able to sort out any family violence within the community. So as you see the roads are really narrow even access of ambulances is a challenge. So we look at the bottom left the informal settlement the slums. Most of this make up almost 61% of our population within my country Kenya the informal settlement and the slums and this is where majority of the population lives when we look at that slum area it's an area where you will find children have nowhere to play you're living in one small room almost 10-15 people so it's really a big challenge to most of those communities and that's also a place where access to mobile phone access in case of calling in to a toll-free line is still a big challenge because yes they do have mobile phones many of them but economic times have made them inaccessible in terms of being able to meet a phone call ambulances cannot access these areas. If you need to call an ambulance you'll have to also walk a distance and as we'll see later capules and lockdowns have also been imposed that have hindered that capability to access on the bottom left without the lovely little hats this is the rural community where I work they are the farming communities where children have access to a long area of land and capabilities to play but also here they face a lot of challenges in terms of being able to access the nearest facility which could be kilometers away from where they are at night when domestic violence does occur this can really be a big hindrance in an issue where in the rural areas. For community in the rural areas we've got very good functional working community help workers. We've also got a good network of the Nimbacumi initiative and elders who do a great job in terms of mitigating those family violence incidences. Next slide please. So we are also having the same measures that have been put up in other countries in the west. Africa has engaged quarantine and within the quarantine strategies you'll find most of our countries are using institutions to quarantine the contacts and people who are suspected to be COVID-19 positive as they await their results or as they await to be cleared for their 14 days quarantine period. These areas are quite challenging because once you are confined in your quarantine centers these centers are geometries or areas where you're sharing with people you do not know if you are a family you'll end up being separated within your quarantine centers because it's the main areas there's the female areas and there's the children areas. So you end up finding and asking yourself what happens to my family, what's happening in those areas because you do not know the other person what about violence, what about sexual exploitation in these quarantine areas. So those are also changes that we are facing. There's the intercity travel restrictions and lockdowns which have put families apart. Most African countries you'll find spouses work in different towns. Children may be living in the rural areas with their grandparents and care may not be the same when you do not have your parents and families together or your spouses and partner together with you. So this has also fueled SGPV in some families and within some areas. Closure of schools and university brought children and teenagers all together within the living setups that have shown up there and each comes in with their own behavior and practices that they have been engaged with and puts a lot of compromise and fuels SGPV within the homes stay at home orders looking at the two kinds of settlements that we have the living disparities within the African setup you find that people really have a challenge staying at home in such small spaces and having to work also at home in such small spaces and this also fuels gender-based violence it fuels sexual exploitation of the younger ones when we have nothing else to do in a very small space night cafes yes they are good they brought people home but some are coming home to a very small space and some have had very difficult living arrangements within their homes and some homes have had domestic violence last week I had two brothers who started each other because they had domestic films which they were having for a very long time but had not seen each other but now have to live in the same home and they had to settle their differences at home so it's not just sexual it's not just gender-based but it's also sibling rivalry that's also being ignited by these night cafes. Next slide Joy we are really really pressed in time so if you could go quickly please for the last one sorry. Yes it's the last slide so in terms of incidents and challenges we've got a large number of calls and call centers men being majority of the callers but this also has been highlighted by UNICEF in terms of the fact that majority in terms of owning funds and women have less. We don't have shelters to house victims but these are things which can be worked on by governments minus don't have funds so it becomes difficult to use toll-free lines and then there is the overwhelmed healthcare workers who are already mitigating the COVID challenges sorting out essential services and in addition now adding up the sexual and gender-based violence issues. So I'd like to say thank you to the whole team and thanks to the panelists. Thank you we will now pass to Anna right if we have time for a little bit. Yeah question. Good we just discussed behind the scenes here if we should extend the session a little bit because we're running out of time and there are a few comments and questions which might be interesting to discuss and reflect on. There is one quite technical issue which is addressed in the incoming channels. I suggest that we take that one first and maybe a couple of you if you have experience could answer to that and then most of the reflections and questions are around communication and different aspects of how to communicate with patients at risk of or in family violence situations. So let us take the technical one first and that is have any of you been able to work with police to identify trends in the community in this aspect of family violence. Anyone who has experience there is Nina and there is Joyce why don't we give it some short sharing here Nina. Yes thank you Anna and thank you to the author of the question I must say that working with police has become more or less a common way of dealing with some of the cases of violence therefore the police in my country appointed a certain officer to be at our disposal sometimes he does come sometimes to the interdisciplinary meetings at the medical chamber that we have otherwise if not a meeting but a very concrete answer is needed he is available on the email and on the phone and I must say he was very very helpful in a lot of times because we do realize that we don't know all kinds of police has hope I answered the question thank you. Joey for you. Thank you very much Anna yes in our country we have every police station has agenda desk that sorts out most of the violence cases where I work we have what we call a court users committee these campuses not just the judiciary the police the elders the church leaders and brings us all together once a month we discuss the issues of gender based violence but now with this COVID issue we are doing it more on a weekly basis good shall I go on I said most of the comments and questions are around communication so let me start with one which will bridge to some of the more particular questions which just came in it goes like this is the definition of violence the same for all scenarios should I put my beliefs of what violence is verbal violence physical violence disciplining children with slaps for example or should I take into account the social context this is a hard one but extremely important and I can tell you while you are now contemplating who to reply this has been touched on by other participants as well and I think how I understand the comments and questions how to overcome barriers of language and cultural codes we are a global organization and we also have the diversity in our different context where we are working so who is to decide what is well, unmute okay thank you for this very important question in my view in fact as a general practitioner we are not looking for violence we are looking for the problems that people present to us in problematic situations we go into interaction and communication about the situation and we can give our message that we actually as I think Jean did during his consultation think that we consider this as a case of violence and the patient like Medina can answer that in her view it's not abuse or it's not violence but the most important thing is in a problematic situation which needs coping so what we need to do is to communicate actually how can we help you in this situation how can you cope and what can we actually do for improving the situation and then it comes to a genuine consultation between the client and the practitioner to understand the situation and to come to a common understanding when I showed this circle with events whatever they are violent events or neglect or economic or quarreling or slapping and the thoughts which are around there and then eventually new emotions fear going home or being together or anger of the perpetrator then something needs to be done with this whole situation and it's not important how you call it it's important to name it as a general practitioner we understand it's violence but the person can think about the answer but we must think together about the solution Sergio, you wanted to say something to this? Based on my experience at the time the terminology does not exist among the victims so when we say domestic violence they could not comprehend it so sometimes when we use bombastic word the word that especially when we use among the academics they may not understand it but when we ask them to explain their situation and we ask them whether right in your situation you sense that this is something not right with you I think that would be easier to open up the communication because sometimes either they do not have the terminology or they minimize it or to them this is common occurrences in their family so to them it may be normal for example their parents got partner violence domestic violence they are in laws having that so they thought this is normal so when we say you are in an abusive relationship or this is violence they may have problem understanding the terminology this is in terms of answering the language bit Thank you very helpful we have a challenge to all of us here and that is what would be the most threatening word to use and not to use abuse we leave it there we can think about it because this is also a contextual I mean to answer this it has to fit to the context you are in speaking about yeah Jean I just want to sort of dovetail with that because I think it is so key that we use the language that we and our patients find comfortable there isn't a strict protocol for how to ask these questions of what language to use it really needs to be tailored even within a country we have different consulting styles and different languages I think part of the the prowess part of the competence of family medicine is to be able to craft your narrative with your patient understanding each other and I think if any group of professionals can do this it is us because we are doing it all the time in our consultations and I think we should own the sort of expertise that sits behind this and indeed to use the language that is somehow mutually acceptable follow up then on training because this is also about training how to come around this problem from the comments coming in here and I also see some activity from young doctors here the role play you showed us I think if we have some years of experience it resonates with what we saw that this was real authentic if you do not enjoy the long term relationship with the patient and in addition is younger than the patient in question maybe she could be the age of your mother even your grandmother it is hard to it's hard to approach do you have any good advice to young doctors to to I mean train in this area because we have experienced doctors have the extremely important knowledge from long term relationships if you don't have that it's hard also to gain the trust so any comments on that I will take that first then if anybody wants it's very important for young doctors and older doctors as well to educate themselves about this so there are a lot of materials available online and you should also ask for who is training you if you are a resident ask for it we have our colleague Raquel doing a PhD on this topic of how is it being taught and there are more and more places in the world where it is becoming a mandatory topic for family doctors which I definitely think it should be ok now what is very important in the training is actually to have it hands on and even if you don't have a very good training you can do role plays with your friends with the other trainees and practice it before the real situation and then you can see what are the good appropriate sentences questions and replies that you can use that you would feel comfortable with them you can always take it and have a look at it afterwards and learn from it so we are also on our special interest group site of course with some materials and with our email that you can contact us if anybody else wants to comment on the same question Raquel you haven't said anything so far Yes just underlining the words of Haggit is one of the huge barriers for doctors or healthcare workers not to explore or ask directly there is any situation of violence is the lack of training so it's important to train the healthcare professionals because we are the first line in dealing with these problems so it's our responsibility to be well trained to address properly Neno Yes thank you Anna I would like to use this opportunity as NCR or the Wonka family obviously to invite all the attendees and all the interested young doctors to our future workshops which we always have on the Wonka Europe world or Asia meetings there are at least three or four every year they are clearly designated with our names, Special Instance Group for Family Violence, and all are welcome. Look, time is running. I think Garth, we will close, and Donald will give his closing remarks. I'll just, time for one small question. I think we then circle back to what we started with. Maybe. In this session, part of the session, which I think is a common one for all of us, regardless of how experienced we are, what to do if you, as a practitioner, see that there is abuse, but victim is resisting to bring police in. Do you ignore the victim and still inform the police? This is, of course, also a matter of local legalities and law, but, I mean, as the doctor, what do you do? One short answer, and then, yeah, Jean is on the ball. Well, I just think this comes back to the issue of respecting the agency of the woman, usually the woman, maybe the agency of the man if it's a male victim. And I think if children are not being affected above a certain threshold, if the woman has capacity and she doesn't have a learning difficulty, then my bias is to stick to her decision about what to do. And it's a matter of judgment, and in some countries, it's not up to the doctor, because there's mandatory reporting. But I think we as family doctors, if any group of doctors understand this, is to try to support the agency and the empowerment of our patients. So that's where I would come off the fence, if faced with that difficult question. That was a wonderful bridging over to Haggit before you turn the words over to Gartha and Donald. Haggit, a couple of comments. Could only, Harris, could you just show our last slide exactly this one? We are not going to tell you, it's going to be easy, but we are going to tell you that it's going to be worth it because you can really, really save lives. Also with addressing family violence. Next, please. Thank you to all, wait. I just forgot to say thank you to all the people that helped us in the presentation from our special interest group. So thank you everybody. Next, please. And we have our site there. We will be posting on the Onka COVID resource, an updated page with many, many links and resources. And we will also try to put the presentations from today in a shorter version so everybody can use them. Thank you very much again to everybody. Wonderful, thank you Haggit. And I'll hand straight over to Donald for his concluding remarks. Donald, over to you. You'll need to unmute. Donald, you're muted. Thank you. Yeah, thank you. Yeah, okay. Thank you panelists for leading a wonderful presentation and all of you for tuning in. I think this session reminds us that family medicine is about people. All we were talking about is also people-centered care about respect, about trust. I think the only, I would add one comment is that we have to take into consideration of culture, beliefs, religions, and traditions as well when we deal with violence. But I think we've learned a lot and it will help family doctors deliver holistic care to our patients which includes dealing with violence and these challenging situations. Before I say more, I'd like to introduce Nick's week and invite everybody to join us same time, Sunday. And our topic next time would be on primary health care for universal health courage during the COVID-19. Nick's please. The webinar will focus on the main success factors and the areas of improvement in the primary health care response in this pandemic as well as ways to increase preparedness for the near future and the next global health crisis. And we're privileged to have distinguished panel, two directors from WHO, as well as our wonkelizing person, Viviana, out of you know, and I'm sure it'll be a very lively discussion. So do tune in and register and participate. So to conclude, I just want to say this is a pandemic with an unknown end game. I wish each and every one of our family doctors well during this time. Use the best advice available. Work collaboratively with your teams. Do the best you can for your patients. You should stand proud of your contributions to tackling this world crisis. Nick's please. No one knows what we will face in the weeks and months ahead, but everyone knows enough to understand that COVID-19 will test our capacities to be kind and generous and to see beyond ourselves and our own interests. Our task now is to bring the best of who we are and what we do to a world that is more complex and more confused than any of us would like it to be. May we all proceed with wisdom and grace. Thank you very much. Thank you so much Donald. And thanks to Haggit and Naina and all of the panelists. There've been lots of comments and questions streaming in. And thanks to the three monitors Raquel, UC and Elena for the work that they did in monitoring and then to Anna for moderating. So great work everybody. We look forward to, it was a really good session. I think there were really good presentations and thank you all for all the effort you've put in. Next week I think we'll be great as well. And as Donald says, we've got two WHO directors joining us, which is fantastic. So we'll see you all next week. Have a good week everybody and stay safe. Thanks a lot.