Development of a Complex Intervention to Improve Bruise Evidence in Victims of Violence and Across Variations in Skin Tone

Darker skin contributes to health and criminal justice inequalities between ethnic groups. Bruising is harder to identify and document in those with darker skin, which has implications for those injured due to violence. Non-fatal strangulation, for example, may not require treatment in the Emergency Department (ED), but it does predict future serious injury. Revision to legislation in 2021 (Section 70 Domestic Abuse Act) recognises this and the importance of identifying and evidencing bruising related to assault. However, poor ascertainment in those with darker skin leaves victims feeling that they are not taken seriously, their bruising is not noticed and evidenced by practitioners, which reduces access to justice and healthcare. Limited evidence further biases safeguarding decisions. This issue is not unique to victims of violence. Dermatologists find that skin conditions are missed in those with greater skin pigmentation. In response, cross-polarising filters have been developed in dermatology to see beyond skin pigmentation and provide clearer photographs of abnormalities. These filters can be attached to cameras, and research indicates that they also improve the identification and photographs of bruises. Our aim is to develop an intervention that uses these filters for use by frontline practitioners. Attending police officers and other frontline staff routinely carry out risk assessments and photograph (using their work phone) evidence of injury. However, our Public, Patient Involvement contributors and broader engagement has identified several barriers that need to be mitigated in our development of this intervention. (i) The current guidance on how to collect evidence of a bruise is dated and only relevant to people with white skin. We want to identify opportunities to update it. (ii) Trust in frontline policing varies, with some people actively avoiding engagement. (iii) Some may avoid scrutiny by healthcare specialties. (iv) Other healthcare specialties (e.g. GPs, dentists, sexual assault referral clinics, paramedics, staff in refuges) may also benefit. We seek to understand any victim reluctance, what can be done to overcome it, and which professionals are best placed to use the device. Diversity in skin pigmentation is also associated with ethnicity and therefore variations in cultural expectations on how victims should respond to violence. (v) We seek to capture these variations and how they might impact on the intervention. (vi) We want to identify and overcome any language barriers, for example refugees may have limited English or Welsh. Finally, while using the device is straightforward, this is a complex intervention, and (vii) we aim to identify the training needs of practitioners to collect evidence to current evidential standards as well as addressing cultural factors. We want to eventually evaluate the device in a community setting. Before doing so, (viii) we need to identify outcomes that demonstrate the value of the device. These outcomes include emergency care contacts, visits to ED, mortality and serious injury, and related outcomes including charging of and the prosecution of offenders, which in turn influences victim safety. However, we would also wish to capture outcomes specific to victims including self-reported quality of life and seek to develop insights through engagement with survivors. Our aspiration is for an intervention that is acceptable and addresses healthcare inequalities associated violence and being in a minority ethnic group.