COVID-19: a public health approach to manage domestic violence is needed.

The negative consequential effects of the measures adopted by the UK and other countries to tackle the spread of coronavirus disease 2019 (COVID-19) on society are beginning to unfold. An area of concern is the impending crisis of domestic violence—gender-based violence and child abuse and neglect, due to movement restrictions, loss of income, isolation, overcrowding, and stress and anxiety, all which put women and children at a disproportionally increased risk of harm. This increased risk is not surprising. Previous epidemics, such as the Ebola virus disease outbreak in west Africa, but also cholera and Zika virus disease outbreaks, led to regional environments where domestic violence became more prevalent; there were reductions in funding for specialist gender-based violence public health services; and, for survivors of gender-based violence, there was reduced access to health-care services. Although we are not aware of published studies to date that have tracked the national trends in gender-based violence related to COVID-19, initial reports from UK support services such as the National Domestic Abuse helpline have already shown increases in service use, a pattern seen elsewhere (with notable examples in China, Spain, and France).

In the UK, before the coronavirus crisis, gender-based violence was already deemed as highly prevalent, associated with substantial negative downstream social, psychological, and physical outcomes. Therefore, any resultant increases in the rates of domestic violence would not only be a further travesty of human rights but also be associated with further long-term costs to society, which might be irreparable beyond the immediate threat of COVID-19. It has never been more important than now to implement a public health approach to gender-based violence in the UK.

Similar to an approach that has been put in use to improve the management of physical violence in cities such as Cardiff, Glasgow, and London, the principles of a public health approach should be implemented to support survivors of gender-based violence. The WHO public health approach consists of four steps, which we have suggested the adaptation of to aid in the prevention of domestic violence during this pandemic (appendix).

Without adequate surveillance, it is not possible to capture the burden of domestic violence during this pandemic. Because of selection biases, administrative datasets have consistently shown underestimates in the expected rates of domestic violence. Potential approaches to improve the surveillance of domestic violence could include the routine inquiry (feasibly integrated into remote primary care consultations or active syndromic surveillance from local health protection teams) and the urgent implementation of linked datasets between police and health records datasets to identify individuals at risk. Enhancing surveillance would also provide the opportunity to offer targeted support and interventions. Though formal evaluations of current interventions have not yet taken place during the pandemic, national charities (such as, but not limited to, Women's Aid, Safelives, and the National Society for the Prevention of Cruelty against Children) have produced guidance for how survivors can both report violence, abuse, and neglect and keep themselves safe, including information on remote reporting and support mechanisms.

There are substantial gaps in the literature relating to the surveillance and evaluation of effective interventions to support those at risk of domestic violence, child abuse and neglect during this pandemic. The medical profession has a duty to provide support in overcoming these problems—to provide a public health approach to supporting those most vulnerable in society.