Introduction

Domestic, family and sexual violence are significant issues impacting communities both within Australia and globally (Garcia-Moreno et al., 2015). Research suggests that this violence not only erodes victim-survivor’s human rights and safety but also affects their health and wellbeing (Potter et al., 2021). The impacts of violence can have significant effects on victim-survivor’s physical, mental, sexual and reproductive health (Webster, 2016).

The World Health Organisation (WHO) has identified that the healthcare system has a key part to play in a multisectoral response to domestic, family and sexual violence (World Health Organization, 2013a, 2013b). Evidence suggests that further work is needed to enhance health sector responses to such violence, with additional research needed to investigate what works, evaluate promising practices, and develop new strategies for prevention and response (Garcia-Moreno et al., 2015; Hegarty et al., 2020; Hegarty et al., 2022). In Australia, heath practitioners are the most frequent professional group told about current domestic violence (Australian Institute of Health and Welfare, 2018). Despite this, in Australia (and internationally) focus on the role the health system plays in identifying and responding to violence is often minimal in key national strategies, with evidence about what works in improving health practitioner’s responses limited (Department of Social Services, 2022; Young et al., 2024). Often the focus of policy, service delivery and research funding is on the role of the criminal justice system, policing and social services (Department of Social Services, 2022). Given the limited funding available to conduct research to support practice in the health sector, prioritisation exercises have been described as being important in ensuring that resources are used to create the greatest impact (Jarman et al., 2023).

While historically research agendas were developed by researchers without input from stakeholders such as consumers, practitioners and the community (Tong et al., 2019), it is increasingly recognised that people with lived experience of the issues being investigated have a valuable role to play in helping set research directions (Grill, 2021; Gulliver et al., 2022). Currently there is a lack of documented evidence concerning the way in which victim-survivors, researchers, practitioners and policy makers have co-designed research priority setting about domestic, family and sexual violence.

To address this gap, the current study aimed to identify:What do victim-survivors, researchers and practitioners see as the key research priorities for improving health sector responses to domestic, family and sexual violence in Australia? as well as outline the methods used.

Methods

A five-stage research process was adopted as outlined in Fig. 1; this included a preparatory phase, one workshop and two rounds of Delphi surveys. Like other Delphi studies, the final research stage involved taking the mean of responses to rank research priorities (Baumann & Brutt, 2022).

Fig. 1
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Study Design Summary

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Preparatory Phase

In the preparatory phase, a systematic search was undertaken to better understand the degree of involvement victim-survivors have had in establishing research priorities for the domestic, family and sexual violence fields and to answer the question, ‘How have victim-survivors been engaged in the development of research agendas and priority setting processes in the area of domestic violence?’ Nine databases were searched, with 2289 papers located, of these, only two papers (Bell et al., 2004; Fisher et al., 2016) described involvement of victim-survivors in decisions about research priorities (See Supplementary Materials for details of the studies). In the preparatory phase, Human Research Ethics Approval was also sought and approved for the later stages of this work from the The University of Melbourne Human Research Ethics Committee (Approval 2023–26,559–40,189-3).

Recruitment of Participants

Participants in the workshop were drawn from the University of Melbourne, WEAVERS lived experience victim survivor co-researchers group and researchers from Australia and overseas who are affiliated with the Safer Families Centre for Research Excellence. The WEAVERS lived experience group was established in 2016 and now has 36 victim survivor members who participate in a range of co-designed research projects, teaching/training and other activities of the Centre. All members of the group are provided with self-reflection questions to support them decide whether they are ready to participate in survivor advocacy and co-design work. They are also provided with ongoing emotional support, supported reflection sessions, training and administrative support. A Survivor Steering Group shares decision-making around how the group operates. Victim-survivors are paid at the same rate as other University Research Assistants (approximately $50AUD per hour with a 2-hour minimum). Victim-survivors were paid for the time they spent on this project (as they are for all projects they are in engaged to support at the University). More information about the Centre’s framework for ethical engagement with victim-survivors is available at https://www.saferfamilies.org.au/codesignframework. During the workshop we paid attention to power dynamics to ensure all voices were heard e.g. first names only, small group work, multiple victim-survivors at each table, varying ways to input ideas (oral and written) and inclusive facilitation of feedback from all tables.

Other stakeholders were not paid to participate in this study as it was expected that they would complete the Delphi in the course of their paid workday. All of the researchers, practitioners and other stakeholders invited to participate were affiliated with the Centre and its mailing list (including those from overseas universities).

For Delphi round 1 and 2, a broader range of stakeholders were invited to participate than in the original workshop (in addition to the above stakeholders) including health practitioners, domestic and family violence/sexual violence services and government sectors. These stakeholders were all part of the Safer Families (redacted for blind review) Centre’s mailing list.

Procedures

Workshop

Similar to other Delphi studies (Ramage et al., 2022), we held a stakeholder workshop (Keeney et al., 2011; Trevelyan & Robinson, 2015). The initial in-person workshop included a total of 35 participants – 8 victim-survivors, 20 researchers and 7 practitioners in a ‘brainstorm’ session. A total of 67 research topics were proposed. Following the conclusion of the workshop the authors completed a review of the research topics. Where there were duplications (often topics were the same but worded slightly differently) then these items were removed. Secondly, topics which were quite similar were merged or grouped together. At the conclusion of this process, 35 research topics remained and were used to form the basis for Delphi Round 1.

Delphi Study

The Delphi approach is often used to identify research priorities in the health sector, (Keeney et al., 2011; Wathen et al., 2012). For this study a Delphi method was used in the context of a multidisciplinary research centre that aims to improve the health system respond to domestic, family and sexual violence. While Delphi studies often vary in their design (Nasa et al., 2021), we used the standard method of two iterative surveys where experts were asked to rank statements. Each round of questionnaires was followed by interpretation and analysis before results were presented back to participants until there was a consensus of opinion (Jarman et al., 2023). As responses were anonymous and items were rated independently, this allowed participants to reflect on their own perspective and answer without pressure from other group members (Richards et al., 2022). As this study included people with expertise by experience (lived experience of family, domestic or sexual violence), researchers, practitioners and policy makers the element of anonymity in the Delphi method was seen as having the potential to address inherent biases like power differentials and group conformity that can arise with the use of other research methods (Nasa et al., 2021).

Delphi round 1

The first online Delphi survey (using Qualtrics software) required participants to indicate on a ten-point scale how important each of 35 research priorities were to ‘improving health sector responses to domestic, family and sexual violence’ (1 = ‘not important’, 10 = ‘extremely important’). It also included an open-ended question asking for additional comments. An invitation to participate was emailed to members of the [redacted] lived experience co-research group, key researchers, practitioners and policy makers.

Delphi round 2

A second Delphi survey was distributed online (using Qualtrics software) to the same list of stakeholders as round 1. The 35 original topics were narrowed down to those priorities that received a mean score greater than 8.00 (22 items) in Delphi Round 1 – this is in line with other Delphi study methods (Evans et al., 2023). Again, participants were asked to rate the importance of each research priority on a scale from 1 to 10 (as per the first Delphi round).

Results

Participants

In total 72 respondents participated in round 1 of the Delphi., with the majority from Australia (64), and a small number from overseas (6) or unknown (2). There were 69 responses to Round 2 of the Delphi; of these, 67 were from Australia. Slightly more researchers (health and DFV) completed Delphi round 1 than round 2 and slightly more victim-survivors completed round 2 than round 1.

Participants were able to select more than one of the categories relating to their main interest or background in domestic, family and sexual violenc with results shown in Table 1. Further, nine participants (12.5%) in Round 1 and nine (13.0%) in Round 2 were researchers, practitioners and/or held another role but also identified as a victim survivor advocate.

Table 1 Participant Characteristics (Delphi round 1 and 2) *
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Round 1 Delphi

Following the first round of the Delphi the ten research priorities with the highest mean rating were identified. Five of these related to improving response to children and young people who have experienced domestic and family violence, or families with young children. Of the remaining five priorities, three related to better understanding the needs of and/or supporting victim-survivors from diverse or marginalised populations. The remaining two topics were:

What innovative ways could health funding better support the needs of victim-survivors of domestic and family violence?

How can we embed victim survivor voices in health sector reform?

The mean ratings each research priority received in round 1 and round 2 of the Delphi can be found in Table 2 (Supplementary materials).

Round 2 Delphi

For the second round of the Delphi, 13 research priorities were omitted (leaving 22 items – see Table 2). Findings from Delphi Round 2 saw some variation from the first Delphi round however research priorities relating to improving outcomes for children and young families, marginalised/diverse populations and the importance of reform engaging lived experience through survivor voice were still rated highly. Table 2 below outlines the top 10 research priorities from the Delphi Round 2.

Table 2 Research priorities with the highest mean rating after round 2 Delphi
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In summary, the findings from the two rounds of Delphi surveys found a degree of consistency in the types of research areas seen as priorities by key stakeholders. We grouped the priorities into four themes – 1) embedding the voices victim-survivors of domestic and family violence in health sector reform; 2) improving outcomes for children, young people and young families; 3) strengthening response to victim-survivors and perpetrators; and 4) better meeting the needs of victim-survivors from diverse backgrounds.

Discussion

A Delphi methodology was adopted by the research team to establish ten research priorities of most importance in improving health system responses to domestic, family and sexual violence. The approach aimed to engage and acknowledge the varied expertise of victim-survivors, researchers, practitioners and policy makers (recognising that some participants fit in more than one category). Key to our approach was our experience engaging with victim-survivors as co-researchers over a sustained period of time.

It has been suggested that there are three key foundations that need to be in place before shared-decision making can occur with people with lived experience in health research priority setting at the relational, environmental and personal levels (Pratt, 2021). These categories overlap but provide a useful summary of some of the key principles we have also found useful as a basis for our co-design work between researchers, practitioners and victim-survivors of domestic, family and sexual violence. At the relational level the importance of forming connections and building trust is emphasised and this is something our team also values. Our lived experience group has been working in partnership with our research team for eight years and that continuity has allowed for the development of genuine relationships, policies for how we work together and a sense of mutuality and reciprocity between researchers and victim-survivors. The importance of ensuring the right environmental infrastructure is in place to support and build the capacity of victim-survivors is also something we see as important. While we provide training, emotional, administrative and logistical supports for our victim survivor group, access to ongoing sustainable funding to deliver genuine, ethical lived experience engagement is an ongoing challenge. The importance of ensuring everyone involved in the engagement of people with lived experience is coming to this work with the necessary personal attributes particularly an openness and willingness to share power and decision-making is also one we see as key. To this end, we have developed self-reflection questions both for victim-survivors but also for researchers considering engaging in co-production research activities with victim-survivors of domestic, family and sexual violence.

Given support for the engagement of consumers in health research is gaining prominence, especially those from marginlaised groups (Pratt, 2021) , it is important to have conversations about the fundamental elements that sustain ethical engagement. In the current study, the research priority which focussed on exploring ‘how can we embed victim survivor voices in health sector reform’ was rated very highly by participants (second highest in round 1 and fifth in round 2). Our participant demographics show that a number of people with lived experience of domestic and family violence completed the surveys. It should be noted that this included both those who are members of our victim survivor group but also those who are also researchers, health practitioners or policy makers who also identify as victim-survivors. These findings are consistent with other work that shows people working in the heath system have higher rates of lived experience of domestic violence than the general population (McLindon et al., 2022). This is an important consideration to bear in mind when engaging with stakeholders in this space.

There is growing support and high level agreement within the domestic, family and sexual violence sectors that engaging survivors is an important way to inform policies, services and prevention strategies (Wheildon et al., 2023) and the increased interest in exploring what constitutes ethical co-design with victim surivors (Lamb et al., 2020; Lamb et al., 2023). However in Australia and elsewhere, while the mental health sector has invested in the development of strategies and mechanisms to systematically support lived experience engagement (Palmer et al., 2023), the domestic and sexual violence sectors have not seen investment in the same resourcing to allow capacity building, testing and evaluation of approaches. The fact that a desire to research ways to better embed victim survivor voices in health sector responses to domestic, family and sexual violence was consistently rated highly across both those with lived experience as well as other respondents in this study, is an important finding.

Research priorities relating to responding to children and young people (and young families) who have experienced family and domestic violence were also rated highly across both Delphi rounds. This is likely due to widespread acknowledgement that there is a dearth of current research and understanding about effective interventions for children and young people who have experienced domestic violence (Howarth et al., 2016) and significant public debates about this issue were particularly live in Australia at the time this study was undertaken (Fitz-Gibbon et al., 2023).

The study also found considerable support for prioritising research to support health practitioners better meet the needs of victim-survivors from diverse backgrounds (such as those with a disability, mental health challenges, from the LGBTIQ community or culturally diverse or Indigenous backgrounds). Research priorities relating to diverse or marginalised populations of victim-survivors, comprised four of the final ten highest rated research priorities (round 2 Delphi). Other studies on priority setting in sexual violence research, have found that those concerning specific challenges and barriers faced by diverse populations also rated highly (Varese et al., 2022).

Research priorities relating to people who use violence were not highly rated across the Delphi/Workshop process, although this is widely acknowledged as an area where there is a large research-practice gap (Murray et al., 2010). Three of the four topics relating to people who use violence were removed from the Delphi after round 1; the remaining one was ninth in the final top ten rated priorities i.e. How can health practitioners better identify and respond to people who use DFV? This topic was slightly different from the three others – it focussed less on gaining an understanding about people who use violence and more about how health practitioners should identify and respond. It is possible that these findings should be looked at in the context of historical tensions about the allocation of scarce funding in the domestic violence sector towards perpetrators, leaving less for victim-survivors (Brown & Hampson, 2009; Humphreys et al., 2008).

Other research priorities which received low ratings in the first round of the Delphi (and were therefore omitted from round 2) included one relating to responding to the lived experience of professionals and another relating to the impact of vicarious trauma. In some ways these are potentially linked. Evidence suggests that health workers are likely overrepresented as victim-survivors of domestic violence, and people with lived experience of trauma more severely impacted by exposure to vicarious trauma than other professionals (McLindon et al., 2022). It is unknown why stakeholders rated these priorities lower than others. However, it is possible that the issues were considered important but just not as important as improving responses to victim-survivors. In addition, the tendency for health practitioners to focus more on their patient’s wellbeing than their own self-care has been well documented (Linton & Koonmen, 2020; Nkabinde-Thamae et al., 2022).

Strengths of this study are that the inclusion of the perspectives of people with lived experience, researchers, policy makers and practitioners from the health and domestic violence sectors ensured the research agenda priorities were considered through a range of lens. We also had higher rates of completion of the Delphi surveys than previous work in this area (Wathen et al., 2012). The limitations of the Delphi method include reliance on subjective opinions and arbitrary decisions about who participates (Murray et al., 2010). Limitations specific to this study were the variable response rates to items in the Delphi rounds with not all participants providing ratings for all research priorities (see Table 2 for response rates). While most priorities received high response rates, one consistently received lower rates of response than others: How can health practitioners and Indigenous health organisations partner to identify and address the health needs of victim-survivors? The reason for this is not known, but it is suspected that respondents may have felt that this was a topic that required expertise and/or involvement in Indigenous policy and practice to provide judgement on its merit as a priority. For those that did respond to this priority item, they rated it very highly.

Conclusion

In the context of increasing interest in engaging victim-survivors in research about domestic, family and sexual violence, this study showed that a Delphi method is one way of engaging a broad range of stakeholders including victim-survivors in research priority setting. The study found that stakeholders identified four key areas of research priority: embedding the voices victim-survivors; improving outcomes for children, young people and young families, strengthening response to victim-survivors and perpetrators, and better meeting the needs of victim-survivors from diverse backgrounds. The consistently high level of importance given to embedding survivors in health sector reform found through the Delphi process also supported the inclusive approach taken. The study findings give researchers, post graduate students, funders and policy makers some guidance around areas for prioritisation in future research projects designed to improve health system responses to domestic, family and sexual violence.