COVID-19: Adaptations to Primary Care in Australia

COVID-19: Adaptations to Primary Care in Australia

James Pietris 1 1 Bond University

James Pietris is 4th year medical student at Bond University, and originally hail from South Australia but have resided in Queensland for the last 4 years.

Key learning points

• Effective implementation of telehealth in primary care settings in Australia can help to reduce the transmission and spread of COVID-19. • More evidence is required to accurately assess the effectiveness and practicality of the public use of face masks. • Despite being incredibly effective at reducing the spread of COVID-19, physical distancing has resulted in devastating economic impacts globally.

Abstract

Introduction: The Australian Government has implemented its National Primary Care Response action plan to combat the growing threat of the COVID-19 pandemic across the country. The plan recognises the integral role of primary care services in protecting the most vulnerable citizens of our nation and recommends a number of interventions aimed at reducing transmission, including expanding telehealth services, physical distancing measures, and the use of personal protective equipment. The efficacy of these suggested measures needs to be evaluated to ensure everything is being done to maximise the safety of Australia’s primary care system while maintaining the highest level of care possible. Summary: This review article delves into the benefits and limitations of the interventions suggested in the National Primary Care Response action plan and formulate recommendations on each intervention based on the currently available literature. Based on the literature findings, recommendations have been made to implement telehealth, physical distancing, and face masks in primary care settings across Australia to curb the transmission of COVID-19 across the country.

Keywords: Telehealth, physical distancing, primary care,

COVID-19, coronavirus.

Introduction

Since late December 2019, a novel coronavirus COVID-19 spread rapidly across the globe from its origin in Wuhan, China, causing pneumonia-like respiratory illness. A global pandemic was officially declared on 11 March 2020 [1]. Lessons learnt from past outbreaks of disease underline the critical frontline role of primary care, and the need for clear, regular communication between the community and the primary care workforce [1]. In early March, as part of the Australian Health Sector Emergency Response Plan for the novel coronavirus, the Australian Government announced the National COVID-19 Primary Care Response, an action plan that aims to protect the nation’s health care system and most vulnerable citizens through facilitating rapid implementation of initiatives to optimize workforce capacity, efficiency, and safety. The four key objectives to the Primary Care Response are: 1. Protection of vulnerable citizens, 2. Function of the healthcare system, 3. Support and treatment, and 4. Capacity to maintain stocks of personal protective equipment [2]. Many components are integral to the Primary Care Response. These include the creation of General Practitioner (GP)-led respiratory clinics, public fever clinics, changes to influenza vaccination recommendations, and increasing research funding, among others. This article will focus on three of these components; the expansion of telehealth services, the implementation of physical distancing measures in face-to-face consultation situations, and the use of personal protective equipment (PPE) in primary care settings. These components have been chosen to reviewed as they have been the most publicised and implemented strategies across Australia during this pandemic [3]. Evaluating the available evidence of the efficacy and practicality of these measures in the primary care setting will provide valuable insight into the value of the implementation of these measures across Australia.

Methods

A literature search was performed of trials published from 2005 to 2020 involving telehealth practices, physical distancing, and past and current global health emergencies. The search terms and keywords used were ‘telehealth’, ‘physical distancing’, ‘primary care’, ‘COVID-19’, and ‘coronavirus’. Four databases (EMBASE, Google Scholar, Cochrane, and PubMed), were searched. The inclusion criteria required the studies to be published in English language journals, published between the years of 2005 – 2020, and be sufficiently relevant to the topic of the article. Using these inclusion criteria, 12 scientific articles relevant to the topic were chosen to include. Local and foreign government websites were also searched for relevant official documents, policies, and statistics.

Telehealth

Telehealth use – using technologies to promote and support long-distance clinical care – has over the past decade seen a dramatic increase in correlation with the increased frequency and severity of disasters across the world [4]. There is strong evidence for the efficacy of using telehealth to decrease patient flow through primary care facilities and emergency departments alike, decreasing the strain on these facilities and allowing them to operate more efficiently [5]. The American city of Houston has rolled out mobile home healthcare units to chronic disease patients at home, allowing remote monitoring of these patients to prevent their repeated exposure to healthcare workers through in-person primary care consultations and emergency department admissions. Implementation of these measures showed a 56% decrease in exposure to healthcare workers compared to the control group [6]. In Australia, the accessibility of telehealth for people in rural and remote communities is another big advantage. Patient care can be more effectively delivered with less patients lost to follow up as the need to travel to consultations will be much less frequent, and access to services for people in areas where there are no local health services will be increased [7]. In addition to this, the cost of providing telehealth services is minimal, with each consult resulting in net savings mainly due to the avoidance of travel costs [8]. With rapid implementation of new initiatives comes unique limitations, and these are evident with telehealth. A major concern of telehealth consultations is patient confidentiality and privacy. Due to the remote nature of telehealth, the confidentiality of the consultation cannot be guaranteed by the practitioner and sensitive health information may inadvertently become the knowledge of a larger than intended group [9]. The Australian Government, in conjunction with the Royal Australian College of General Practitioners (RACGP), has provided guidelines to be used to maximise the confidentiality of telehealth consultations. These guidelines recommend verifying the patient’s identity and the identity of anyone else in attendance, confirming verbal consent, and keeping accurate and up to date documentation in the same manner as is required for a face-to-face consultation [9]. These measures are designed to optimise the privacy of patients while still allowing an effective consultation but are still far from comparable to the level that can be achieved in a traditional consultation. Most telehealth services are being delivered via telephone in Australia and hence availability is not an issue, but adequate platforms for the delivery of video services, such as tablets or computers, are not immediately available in numbers large enough to service entire countries, especially with the disruptions in international supply chains that have been seen throughout the COVID-19 pandemic. The standard of patient care delivered through a telephone consultation must be questioned when the visual cues of the patient cannot be interpreted and the level of understanding gained from body language in a traditional consultation is lost. Hence, this can potentially adversely affect patient outcomes [10]. Thus, the quality of care delivered through telehealth compared to traditional consultations must be questioned, and more research is needed in this area to allow a direct comparison of care before telehealth can be considered a viable alternative to traditional face-to-face primary care.

Physical Distancing

Physical distancing measures have been perhaps the most widely implemented initiative across the world in response to the COVID-19 pandemic. There is ample evidence to emphasise the benefits of physical distancing with respect to reducing both the severity and number of cases [11,12]. The basic reproductive number, R0, reflects the number of individuals directly infected by an infectious person in an otherwise susceptible population. The lower the R0 value, the lower the number of newly infected people. An R0 value of 1 suggests a disease is endemic, whereas if R0 is less than zero, the case numbers will likely be in decline. The R0 value is influenced by the number of contacts an infectious person has, the risk of transmission per contact, and the duration of contagiousness of the disease [13]. Physical distancing principles mostly relate to the first factor – reducing the number of contacts an infected person has. The second concept to consider is the notion of a negative multiplier effect. The negative multiplier effect refers to the exponential decrease in case numbers that is seen with effective physical distancing measures, as illustrated in Figure 1below [14]. It can therefore be suggested that implementation of adequate physical distancing measures in the primary care setting, as well as the wider community, will lower the rate of transmission and hence reduce the R 0 value, contributing to reduced overall numbers of the disease. With regard to primary care, there are a number of very simple physical distancing measures that can be immediately implemented to reduce infection rates and transmission. These include no handshaking, coughing, and sneezing etiquette (into the elbow), paying by card instead of cash, and making videoconferencing the default for staff and multidisciplinary team meetings. These measures and their swift implementation are all supported by the World Health Organization [15]. Limitations to the implementation of physical distancing are relatively minimal, as the above measures are free of cost, not impacted by supply chain disruptions, and are effective across all demographic groups. However, the economic cost of physical distancing has been significant. Industries such as hospitality, live music, air travel, and tourism have all been severely affected. Restrictions on international and domestic flights, as well as laws preventing large gatherings of people have resulted in steep downturns in business, resulting in an estimated $34.2 billion decrease in Australia’s gross domestic product (GDP) over the next year [16]. In addition to this, the practicality of enforcing physical distancing rules in every domain is limited in certain situations. Essential services such as public transport and grocery stores see a large amount of unavoidable foot traffic throughout the day, and hence it is difficult to practice physical distancing in these settings due to the inherently high demand for these services [17].

Personal Protective Equipment

It is universally agreed that personal protective equipment (PPE) is essential to prevent the spread of COVID-19 to healthcare workers in the hospital setting. The use of PPE by the public, particularly face masks, is much more contentious, especially

when it comes to environments outside the hospital, such as the primary care setting. Surgical face masks are protective against medium to large droplet spread, and N95 masks are protective against small droplet spread [18]. The literature in this area is rapidly changing and there are many contrasting conclusions on the benefits and risks of mask use outside of hospital facilities [19]. A review conducted by the Bond University Institute for Evidence-Based Healthcare has recently suggested that wearing face masks did lead to a significant reduction in incidence of influenza-like illness, based on observational data from the severe acute respiratory syndrome (SARS) epidemic [20]. Research from the United Kingdom (UK) suggests that widespread community use of face masks possibly reduced the transmission of SARS, and there is clear evidence that face masks should be used in households and facilities that are caring for COVID-19 positive patients for extended periods of time [21]. Recently, a recommendation has been made by the US Centres for Disease Control and Prevention that fabric masks be used at the community level, although due to a lack of data this is based on laboratory studies investigating the effectiveness of different materials at trapping particles of different sizes [22]. It is important that masks fit for use in hospitals are not redirected away from vital healthcare supplies in hospital facilities, and hence supply is the major limitation to the recommendation of face masks in primary care settings as well as in the wider community. More evidence and community input into the effectiveness and practicality of this initiative is needed before a reasonable recommendation can be made regarding the use of face masks.

Conclusion

It is evident that COVID-19 will continue to disperse and circulate across the globe for some time, with waves of infections likely for the foreseeable future. The relevance of the aforementioned adaptations will become increasingly pertinent as the pandemic develops. Due to the rapidly developing nature of the situation, evidence on the efficacy of individual measures in preventing COVID-19 is not widely available. Despite this, there is definite evidence for the benefits of telehealth and physical distancing measures in the primary care setting, and hence it is proposed that these measures be utilised, resources permitting, to their full potential across the Australian primary care landscape. This is further emphasised by the relatively low cost and little harm of these measures. Based on the currently available evidence, a recommendation can be made advocating the use of face masks at the community level to prevent virus transmission, although this continues to be a divisive issue across the country. The Victorian Premier, Daniel Andrews, has since made the wearing of face masks mandatory for Victorians outside their homes. This is an unprecedented step in Australia’s fight against COVID-19, and the outcome of this measure remains to be seen.

References

1. Commonwealth of Australia Department of Health. Australian Health Sector Emergency Response Plan for Novel Coronavirus (COVID-19). Department of Health Web site. https://www.health.gov.au/resources/publications/australianhealth-sector-emergency-response-plan-for-novel-coronaviruscovid-19. Updated February 7, 2020. Accessed May 7, 2020. 2. Kidd, M. Australia’s primary care COVID-19 response. Aust J Gen Pract. 2020;1:AJGP-COVID-02. doi: 10.31128/AJGP-COVID-02. 3. Desborough J, Hall SL, de Toca L et al. Australia’s national COVID19 primary care response. Med J Aust.2020;212. Online without pagination. 4. Lurie N, Carr BG. The role of telehealth in the medical response to disasters. JAMA Intern Med2018;178:745-746. 5. Hollander JE, Carr BG. Virtually perfect? Telemedicine for covid19. N Engl J Med.2020;382:1679-1681. 6. Langabeer JR II, Gonzalez M, Alqusairi D, et al. Telehealth-enabled emergency medical services program reduces ambulance transport to urban emergency departments. West J Emerg Med . 2016;17:713-720. 7. Commonwealth of Australia Department of Health. Better Access Telehealth Services for people in rural and remote areas. Department of Health Web site. https://www1.health.gov.au/internet/main/publishing.nsf/Conten t/mental-ba-telehealth Accessed August 14, 2020. 8. Thaker DA, Moneypenny R, Olver I, et al. Cost savings from a telemendicine model of care in Northern Queensland, Australia. Med J Aust . 2013; 199 (6): 414-417 9. Commonwealth of Australia Department of Health. Privacy Checklist for Telehealth Services. Medicare Benefits Schedule Web site. http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf /Content/Factsheet-TelehealthPrivChecklist Updated May 4, 2020. Accessed May 18, 2020. 10. Maeder AJ. Telehealth standards directions for new models of care. National Rural Health Conference 2009. https://www.ruralhealth.org.au/10thNRHC/10thnrhc.ruralhealth.o rg.au/papers/docs/Maeder_Anthony_A9.pdf Accessed August 14, 2020. 11. Commonwealth of Australia Department of Health. Physical distancing for coronavirus (COVID-19). Department of Health Web site. https://www.health.gov.au/news/health-alerts/novelcoronavirus-2019-ncov-health-alert/how-to-protect-yourselfand-others-from-coronavirus-covid-19/physical-distancing-forcoronavirus-covid-19 Accessed August 14, 2020. 12. Centres for Disease Control and Prevention. Coronavirus Disease information sheet. Centres for Disease Control and Prevention Web site. https://www.cdc.gov/coronavirus/2019-ncov/preventgetting-sick/social-distancing.html Accessed August 14, 2020. 13. Holme P, Masuda N. The basic reproduction number as a predictor for epidemic outbreaks in temporal networks. PLoS One. 2015;10(3). 14. Chu CM, Cheng VCC, Hung IFN, et al. Viral load distribution in SARS outbreak. Emerg Infect Dis.2005;11(12):1882-1886. 15. World Health Organisation. Getting your workplace ready for COVID-19. World Health Organisation Web site. https://www.who.int/docs/default-source/coronaviruse/gettingworkplace-ready-for-covid-19.pdf. Published 28 February, 2020. Accessed May 7, 2020. 16. Pricewaterhouse Coopers. The possible economic consequences of a novel coronavirus (COVID-19) pandemic. Pricewaterhouse Coopers Web site. https://www.pwc.com.au/publications/australiamatters/economic-consequences-coronavirus-COVID-19pandemic.pdf Accessed August 14, 2020. 17. British Columbia Ministry of Health. COVID-19 Guidance to Retail Food and Grocery Stores. British Columbia Ministry of Health Web

site. https://www2.gov.bc.ca/assets/gov/health/about-bc-shealth-care-system/office-of-the-provincial-health-officer/covid19/guidance_to_grocery_stores_april_25_final.pdf Accessed August 14, 2020. 18. Mukerji S, MacIntyre CR, Newall AT. Review of economic evaluations of mask and respirator use for protection against respiratory infection transmission. BMC Infect Dis. 2015;5:413. 19. Greenhalgh T, Schmid MB, Czypionka T, et al. Face masks for the public during the covid‐19 crisis. BMJ. 2020;369:1435. 20. Jefferson T, Jones M, Al Ansari LA, et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Part 1 - Face masks, eye protection and person distancing: systematic review and meta-analysis. Medrxiv Preprint. 2020;1. doi: https://doi.org/10.1101/2020.03.30.20047217 21. Public Health England. The use of facemasks and respirators during an influenza pandemic: scientific evidence base review. Crown Department of Health Web site. https://assets.publishing.service.gov.uk/government/uploads/sys tem/uploads/attachment_data/file/316198/Masks_and_Respirato rs_Science_Review.pdf Published 1 May, 2014. Accessed May 7, 2020. 22. The National Academies Press. Rapid expert consultation on the effectiveness of fabric masks for the COVID ‐19 pandemic. National Academies of Sciences, Engineering, Medicine. 2020;10.17226/25776

Acknowledgements: I would like to express my appreciation to Dr Anne Spooner and Dr Mark Morgan for their valuable suggestions, constructive criticism, and guidance throughout the development of this literature review.

Conflict of interest statement: The author has no conflicts of interest to disclose. Funding: None Author contribution statement: James Pietris made substantial contribution to the conception & design of the work, the analysis and interpretation of data for the work, and final approval of the version to be published.

Cite as: James P. COVID-19: Adaptations to Primary Care in Australia. Aust Med Stud J. 2020;1:748–51.

Correspondence: James Pietris, james.pietris@gmail.com

Date of submission: 15 July 2020 Date of acceptance:: 28 December 2020 Date of online publication: 3 January 2021 Editor: Onur Tanglay Senior Editor: Mabel Leow Proofreaders: Margaret Hezkial, Ke Sun Senior Proofreader: Emily Feng-Gu

Social Distancing and Domestic Violence: An Exploration of the Paradoxical Impact of Our Public Health Response to COVID-19

Sivasaaini Sivakumaran1 1 Bond University

Sivasaaini Sivakumaran is a fifth-year medical student who shares a great interest in advocating for women’s health. Born in Papua New Guinea, she has come to appreciate the importance of women’s health, especially in the global context and aspires to one day be an obstetrician and to volunteer in a few developing countries.

Key learning points

• The COVID-19 pandemic has exacerbated rates of domestic violence. • Public health response and policies in response to COVID-19 have contributed to tipping vulnerable relationships into abusive connections. • Strategies need to be implemented on a legislative and social level to lower domestic violence rates.

Abstract

The public health response and policies implemented during the COVID-19 pandemic have had a substantial influence on the incidence of domestic violence globally. Whilst regulations are in place to protect lives and livelihoods, an evaluation of these measures reveals the paradoxes of such actions on individuals who are vulnerable to such interpersonal abuse. Considerations into the catalysts which prompt such a rise in rates as a result of increased psychosocial pressures are discussed. Furthermore, strategies which could potentially be instigated on a legislative and social level to counter these issues are deliberated.

Keywords: COVID19, Domestic Violence, Women’s Health, Public Health, Social Distancing

Introduction

As the COVID-19 pandemic overwhelms systems globally, the mantra of our governments has always been to “stay home, save lives” [1]. Unbeknownst to some, we are fighting a simultaneous battle of a silent, yet deadly public health issue – domestic violence [2]. Worldwide, one in three women, as well as some men, experience intimate partner violence within their lifetimes [1]. Subjecting these vulnerable populations to lockdown laws where they are forced to spend more time with abusers has facilitated the rise in such rates [3]. The troubling paradoxes which result from social distancing and isolation measures precipitate problems for those who are living in and surviving abusive relationships [3,4]. As a result, this has led to people spending more time at home as they begin to work from home with public entities such as restaurants, pubs, clubs, and many leisure activities having to come to a close. Additionally, many people that have never previously been in pressured relationships of domestic violence have been tipped into experiencing it for the first time during this pandemic [1]. The increasing psychosocial pressures in tandem with households spending more time in close proximity with each other breed opportunities for abuse through surveillance, controlling behaviours, and coercion [2]. A false paradigm is envisaged of a home as a safe haven but in its very nature it can be a place where power dynamics are distorted or subverted by those who abuse [4]. These isolation measures unintentionally prevent survivors from seeking help and reduce their ability to flee from such situations [3].

Discussion

In Australia, an increase in the demand for domestic violence services coincided with the implementation of government enforced restriction policies [5,6]. An 11% increase in domestic dispute call-outs to organisations such as 1800RESPECT and a 75% increase in internet searches relating to domestic abuse were observed [2,6]. This may reflect the influence of government implemented policies but also the loss of jobs, increased global uncertainty, and the lack of access to resources which would otherwise have defused such situations. These trends in statistics are not merely a national matter but are very much a global concern. A positive correlation between the number of reported cases of COVID-19 and domestic violence cases has been identified in countries including the United States, Argentina, France, Cyprus, and Singapore [7]. An article published by The Guardian reported a 25% increase in the reported calls to the United Kingdom (UK) Domestic Violence helpline seven days after the announcement of restrictions by the UK government [1]. Additionally, China - which was the first country to impose mass quarantine – saw a threefold rise in abuse incidents in February 2020 [6]. Perpetrators are capitalising on precautions related to COVID19 to use coercive control mechanisms specifically through the use of containment, fear, and threat of contagion [1]. As echoed by The United States National Domestic Violence Hotline, 5.8% of victims experienced a new form of manipulation from fear tactics of prohibiting access to hospital care and withholding necessary items such as hand sanitisers [3]. In keeping with the unknown of what goes on “behind closed doors”, lockdown

measures have inadvertently granted abusers or potential abusers the ability to act in ways that give them increased power to exploit with less scrutiny from others [4]. Our public health response and policies not only restrict people living in volatile situations of family violence to their homes but also serve as catalysts to tip at-risk relationships into violence [1]. Isolation at home coupled with psychological and economic stressors, stemming from unemployment, fear, frustration, anxiety, boredom and financial burden, increases one’s susceptibility to mental health issues [6,7]. These heightened stressors act as triggers which unravel negative coping mechanisms through excessive alcohol consumption and substance misuse [6]. In Australia, as social distancing measures were implemented, the sales of alcohol rose 36% [6]. Given the closure of pubs and bars, it comes as no surprise that people are drinking more due to boredom and stress release within the confines of their homes [6,7]. With more than half of perpetrators reported to having been under the influence of alcohol at the time of domestic abuse, it becomes apparent that the aforementioned risk factors act as a medium for exacerbating pre-existing familial conflicts adding to the catastrophic milieu [6,7]. Governments and policymakers should use this rise in domestic violence precipitated by the pandemic as an opportunity to implement new protocols and approaches. Although there was some awareness around this matter prior to COVID, planting seeds to create greater understanding will be essential in building the foundation of methods to address this matter. Information about services available locally, such as hotlines, telehealth, respite services, shelters, rape crisis centres, and counselling, should be reinforced through policy change [6]. Stakeholders can integrate discrete reporting platforms into grocery stores or other essential public spaces, as already exemplified in France since May 2020 where pharmacies and shops have initiated emergency warning systems through posters placed in toilets to enable people in danger to use code words like “mask 19” to alert staff [1,6]. On a legislative level, governing bodies should apply a gendered lens to funding and an economic stimulus to industries that are not solely male dominated as a means of allowing both genders to return to work and essentially spend more time outside the confines of their home [8]. Moreover, as seen in the reallocation of funding in Victoria, the 20 million dollar package by the State Government providing accommodation for perpetrators represents a shift in approach we have for reducing family violence [9]. Equally important is to see more women being included in the decision making and planning of interventions to provide a different perspective [10]. Services including therapists and frontline healthcare workers should provide further support and care to survivors experiencing immediate danger and distress during this pandemic [4]. Thus, it is critical for governments to increase the capacity for helpline services, targeted campaigns, and training of these workers to cope with such cases [11]. Providers should also normalise screening by using routine and standardised questions through telemedicine appointments to ensure all patients are aware of resources available to them as well as safety planning if relevant [7,12]. Incorporating screening for domestic violence into COVID-19 testing sites is another way to overcome the barriers to seeking help [1]. The importance of neighbours, friends, and families to encourage conversation and provide support during these hard times is also highly recommended [6]. Equally important is mitigating the psychological trauma after this pandemic has subsided and providing the essential funding to support the mental health sequelae [13].

Conclusion

The COVID-19 pandemic has served as a critical point for individuals to be aware of the repercussions of our emergency health response. Whilst “staying safe” alludes to remaining virus-free, it is imperative during such adversity that we fight for those who are vulnerable and under-represented within the political spheres. In light of the policies set to overcome COVID19, a need to implement guidelines to protect our domestic violence victims is more important now than ever before.

References

1. Anurudran A, Yared L, Comrie C, Harrison K, Burke T Domestic violence amid COVID‐19. Int J Gynaecol Obstet. 2020;150(2):2556. 2. Neil J. Domestic violence and COVID-19: our hidden epidemic. Aust J Gen Pract. 2020;49. 3. Boxall H, Morgan A & Brown R 2020. The prevalence of domestic violence among women during the COVID-19 pandemic. Statistical Bulletin no. 28. Canberra: Australian Institute of Criminology. https://www.aic.gov.au/publications/sb/sb28 4. Bradbury‐Jones C, Isham L. The pandemic paradox: the consequences of COVID‐19 on domestic violence. J Clin Nurs. 2020;29(13-14):2047-9. 5. Mills T. New reports of family violence spike in COVID-19 lockdown, study finds [Internet]. The Age. 2020 [cited 24 October 2020]. Available from: https://www.theage.com.au/national/victoria/new-reports-offamily-violence-spike-in-covid-19-lockdown-study-finds20200607-p55096.html 6. Usher K, Bhullar N, Durkin J, Gyamfi N, Jackson D. Family violence and COVID‐19: increased vulnerability and reduced options for support. Int J Ment Health Nurs. 2020;29(4):549-52. 7. Goh K, Lu M, Jou S. Impact of COVID ‐19 pandemic: social distancing and the vulnerability to domestic violence. Psychiatry Clin Neurosci. 2020; 74(11):612-3 8. Cormack L. COVID-19 recession 'trapping' women in violent households [Internet]. The Sydney Morning Herald. 2020 [cited 24 October 2020]. Available from: https://www.smh.com.au/national/nsw/covid-19-recession-istrapping-women-in-violent-households-20200912-p55uyn.html 9. Clayton R. As more violent men seek help during COVID-19, Victoria's praised for flipping family violence model [Internet]. Abc.net.au. 2020 [cited 23 October 2020]. Available from: https://www.abc.net.au/news/2020-08-19/family-violencecoronavirus-funding-help-perpetrators-leave-home/12567136 10. Sánchez O, Vale D, Rodrigues L, Surita F. Violence against women during the COVID‐19 pandemic: an integrative review. Int J Gynaecol Obstet. 2020;151(2):180-7. 11. Johnson K, Green L, Volpellier M, Kidenda S, McHale T, Naimer K et al. The impact of COVID‐19 on services for people affected by sexual and gender‐based violence. Int J Gynaecol Obstet. 2020;150(3):285-7. 12. Evans M, Lindauer M, Farrell M. A pandemic within a pandemic — intimate partner violence during Covid-19. NEJM. 2020; 383(24): 2303

13. Kofman Y, Garfin D. Home is not always a haven: The domestic violence crisis amid the COVID-19 pandemic. Psychol Trauma. 2020;12(S1):S199-S201.n

Acknowledgements: Thank you to Dr Annelise Wan for guiding me in the production of this article.

Conflict of interest statement: The author has no conflicts of interest to disclose. Funding: None Author contribution statement: Sivasaaini Sivakumaran is the sole author of this manuscript.

Cite as: Sivasaaini S. Social distancing and domestic violence: an exploration of the paradoxical impact of our public health response to covid-19 . Aust Med Stud J. 2021;1:748–51. Correspondence: Sivasaaini Sivakumaran, sivasaaini_1999@hotmail.com

Date of submission: 13 November 2020 Date of acceptance:: 14 April 2021 Date of publication: 17 April 2021 Senior Editors: Mabel Leow, Onur Tanglay Proofreader: Ke Sun, Trung Tran Senior Proofreader: Emily Feng-Gu