Received: 29 June 2010
Accepted: 9 September 2010
This paper draws on the findings of a qualitative evaluation that examines user perceptions of the services provided by an Independent Domestic Violence Advocate (IDVA) to victims of domestic violence in one rural local authority area in the UK. Service users described being reluctant to report experiences of domestic violence but, having done so, finding the involvement of the IDVA invaluable in being able to provide them with the independent advice, information and emotional support that they would not otherwise have received. Although in general they were positive about IDVAs, users could also identify problems due to the telephone based nature of the advocacy that was offered and the duplication of services that sometimes occurred. This paper argues that an IDVA provides an important service to victims of domestic violence, which is likely to be particularly valuable in rural locations. However, the terms of reference for the role need be reviewed in order to maximize the contribution that IDVAs can make.
domestic violence, IDVA, victims
As Hague and Malos (1996) and Fugate et al (2005) have pointed out, the voices of women who have experienced domestic violence have rarely been heard, especially by professionals and agencies who are trying to provide them with a service (see Box 1). This article seeks to address that silence by exploring user perceptions of the services provided by an Independent Domestic Violence Advocate (IDVA) to victims of domestic violence in one rural local authority area in the UK. This focus on IDVAs in the UK is timely because, as Howarth et al (2009, p. 24) have argued, ‘the provision of IDVA services, in the context of wider multi-agency initiatives, forms a central part of the Government’s strategy to tackle domestic abuse.’ The focus on a rural context is appropriate because research has shown wide variations in the provision and quality of services available to victims of domestic violence across the UK (Home Office, 2003), and service delivery in rural areas is frequently a neglected area of study (Pugh, 2000).
This article begins by considering the nature of contemporary criminal justice and social welfare responses to victims of domestic violence in the UK. Next, the precise nature and functions of an IDVA are explored, as well as some of the difficulties encountered when implementing a coherent domestic violence strategy in rural areas. This is followed by a section that explores the literature about IDVA services in the UK. The current research is then introduced and the methods used to gather perceptions about IDVA services are described. Key findings are then presented thematically. To conclude, some implications for practice are drawn out that it is hoped will inform further development of IDVA and similar services in the UK and beyond.
Domestic violence is contemporarily viewed as a significant criminal justice and social policy issue (Hague and Malos, 1996). The scale of the problem is well documented. For example, in the UK it is estimated that one in four women will experience some formof domestic violence at some point in their life (Coleman et al, 2007). Domestic violence has social and economic costs for society, and is also a crimewhich can cause serious physical, emotional and psychological harm to the women and children who bear the brunt of it (Smith-Stover, 2005). Accordingly, contemporary responses to domestic violence have emphasised the importance of so-called ‘joined up’ partnership working (Harwin, 2006). ‘Prevention, protection and justice and support’ for domestic violence victims are key components of the UK Government’s domestic violence strategy (Home Office, 2003, p. 12). To implement the strategy, Domestic Abuse Forums, Specialist Domestic Violence Courts (SDVCs) and Multi-Agency Risk Assessment Conferences (MARACs) have been established within many local authority areas. Based largely on approaches to addressing domestic violence that were pioneered in the USA (Cook et al, 2004), local authority-based inter-agency Domestic Violence Forums, attended by representatives from the police, social services, mental health, criminal justice, housing and voluntary agencies, strategically coordinate policy and practice to tackle and respond to domestic violence. SDVCs, staffed by trained magistrates and prosecutors, are specialist courts that deal only with domestic violence cases. MARACs, which involve many of the same agencies that are involved inDomesticViolence Forums, provide a multi-agency service to individual victims of domestic violence who are assessed, using the Domestic Abuse, Stalking and Harassment and Honour-Based Violence Risk Identification Checklist (Coordinated Action Against Domestic Abuse, 2009), as being at high or very high risk of serious harm. AtMARACs, a victim’s situation is reviewed and actions to protect them, and often their children, are identified.
From around 2003 onwards, attemptswere made in various jurisdictions to ensure that victims of domestic abuse, whether in the community or going through the criminal justice system, had access to independent advocacy and support. In view of the fragmented and diverse advocacy services, a national charity, Coordinated Action Against Domestic Abuse (CAADA), was established in 2005. This developed practical tools and subsequently accredited training to standardise and support the delivery of advocacy services for victims of domestic violence. CAADA’s definition of an IDVA is now reproduced in the national SDVC resource manual, and in relation to the IDVA role it is stated that:
Serving as a victim’s primary point of contact, IDVAs normally work with their clients from the point of crisis to assess the level of risk, discuss the range of suitable options anddevelop safetyplans. They are pro-active in implementing the plans, which address immediate safety, including practical steps to protect themselves and their children, as well as longer-term solutions. These plans will include actions from the MARAC as well as sanctions and remedies available through the criminal and civil courts, housing options and services available through other organisations.
(Coordinated Action Against Domestic Abuse, 2008, p. 1)
According to Howarth et al (2009), MARACs and SDVCs have increasingly come to rely on the existence of IDVAs to fulfil their work. As is highlighted by the above definition, key aspects of the IDVA role are assertive contact, safety planning and linking individuals with agencies that can provide them with appropriate services in order to reduce the likelihood of future victimisation.
Whether an IDVA receives a referral from the police, the courts or a MARAC, one expectation is that they will engage in assertive outreach. An assertive outreach approach is adopted because effective information, advice and support seeking are often lowest among those groups of people who require them most (Genn et al, 2004). Those who experience domestic violence show remarkable inner courage and resilience in their lives (Davis, 2002), although some victims may be reluctant to approach services for information or help (Fugate et al, 2005). Various practical barriers, such as lack of money or time, can make approaching agencies difficult. However, for others, lack of confidence about approaching anyone due to fear of being blamed for their situation may prevent them from asking for help.
After making contact with a victim of domestic violence, IDVAsworkwith them to develop a personal safety plan which will contain details of what actions might be taken, and who the victim might contact, in addition to the police, if further abuse occurs. The importance of a safety focus when working with female victims of domestic violence in particular has been highlighted in research. Kershaw et al (2008) have suggested that domestic violence has more repeat victims than any other crime. Hester et al (2006) found that, during a three-year follow-up period of a sample of 356 men who had been convicted of domestic violence, 40% were involved in repeat incidents of domestic violence against the same victim.
In instances where victims of domestic violence have reported matters to the police, the IDVA serves as a link between the victim and the criminal justice system, providing them with information about court processes and, where appropriate, passing on their knowledge to inform bail and sentencing decisions (Coordinated Action Against Domestic Abuse, 2008). This role is important because victims of domestic violence routinely perceive that the criminal justice system does not take domestic violence incidents seriously enough. Yearnshire (1997) suggests that women are assaulted, on average, 35 times before they report matters to the police. Thereafter research suggests that the overall conviction rate for domestic violence (i.e. the percentage of reported incidents that result in a conviction) is extremely low, at around 5% (Hester and Westmarland, 2005). The proportion of victims of domestic violence who give statements and then retract them is 28%, compared with 10.8% for other crimes (Select Committee on Home Affairs, 2008). The involvement of an IDVA is intended to reassure victims about safety issues, in order to assist their passage through the criminal justice process.
Safety planning with victims of domestic violence, especially if children are involved, can be fraught with practical, legal and emotional difficulties. Because specialist skills or knowledge may at times be required to manage some of these issues, IDVAs are expected to link victims of domestic violence with agencies that can provide them with relevant support or ancillary services, rather than providing such services themselves (Coordinated Action Against Domestic Abuse, 2008). A recurring research finding is that victims of domestic violence are critical of professional involvement in their lives (Yearnshire, 1997). By signposting victims onwards, IDVAs can not only ensure that they obtain expert advice, but can also focus on the traditional advocacy role, which is to promote service users’ needs and wishes to other agencies.
In some areas of the UK there are particular difficulties with regard to implementing the UK domestic violence strategy. In some areas, addressing even basic safety issues is problematic (Grama, 2000) because, for example, there is no local police station or because police response times are slow. The provision of an SDVC in some areas is often impractical because the number of cases in that area does not warrant an SDVC. A centralised response such as an SDVC may require some victims and witnesses to travel a great distance. In some areas, victims may be isolated, and networking them into appropriate services may be difficult. Moreover, in some communities, support advocacy and advisory services may be poorly developed or difficult to access.
The effectiveness of MARACs, SDVCs and associated IDVAs has been evaluated in a number of studies. In 2004, Cook et al investigated the effectiveness of five SDVC models. They suggested that SDVCs offered significant financial savings because they were more likely to ensure that domestic violence was responded to effectively, at an early stage, thereby avoiding an escalation in the severity and frequency of violence. Most SDVCs reported a reduction in repeat victimisation of around 36%. Robinson (2004) considered the effectiveness of MARACs. Respondents reported that MARACs facilitated the accomplishment of many of the key objectives of the Government Domestic Violence Strategy, including information sharing between agencies, contributing to victims’ safety, identifying key contacts within agencies, and raising awareness about the impact of domestic violence on children.
SDVCs and associated IDVA services in one area have been evaluated by Parmar et al (2005). The overall package saw an increase in the number of incidents reported to the police, a reduction in the number of prosecutions being withdrawn (from 53% to 27%, and now at the time of writing 17%), an increase in the number of perpetrators brought to justice (from 8% to 32%), and an increase in the level of reported confidence in the criminal justice system. Finally, the work of IDVAs was positively evaluated in 2009 by Howarth et al. In 57% of the 966 cases that they examined, it was suggested that the abuse had ceased following the involvement of the IDVA.
Despite these findings, funding for IDVA services remains patchy. In some areas, Home Office funding for IDVAs has meant that they have been strategically linked to SDVCs. In other areas, often without a SDVC, funding for IDVAs has come from disparate sources, such as Community Safety Partnerships, local authorities or even substance misuse teams. However, whichever funding stream has been used to establish an IDVA service, it has tended to be short term and limited. Consequently, IDVA services in most local authorities have tended to be fragile and vulnerable to cost-cutting exigencies.
The study arose because members of one Domestic Abuse Forum saw a need to evaluate and, where possible, develop the IDVA service available in their area, which is rural and lacks an SDVC. The intention was to gather perceptions about the IDVA service from service users to inform evidence-based grant applications to fund the service. It was therefore decided that the evaluation would specifically explore the following questions.
• What do women who have been involved with the IDVA say about the service?
• What do women who have received a service from the IDVA perceive as the advantages and disadvantages of the services that are provided?
As Langford (2000, p. 133) has stated, ‘Qualitative research involving battered women requires advanced planning to protect participants and the investigator from the risk of violence from an abusive partner.’ Accordingly, this research was planned with safety in mind and was embarked upon only after ethical approval had been obtained from the researchers’ university- based ethics committee.
Following consideration of safety issues, the service user sample was recruited through the chair of the area’s MARAC. Potential recruits (n = 27), who were adjudged to be safe to contact, received an information sheet about the evaluation and details of what was involved in the research. They were informed that, subject to the limitations imposed by a concern to safeguard children, what they said would be kept anonymous and they could withdraw their consent at any time. Respondents were given the option of being interviewed either face to face at one of several possible neutral locations, or by telephone, by either or both researchers (one male and one female). In total, 14 service users agreed on that basis to be interviewed, and 9 semi-structured face-to-face (n = 5) or telephone interviews (n = 4) were eventually conducted.
Semi-structured interview schedules were developed to be used with service users from a checklist of key topics informed by the research aims. Interviews with respondents were recorded, transcribed and analysed using a qualitative data software package (NVivo 8). Data analysis was informed by a constant comparative, thematic approach. The validity of identified themes was checked across the whole data set and between the members of the research team.
In total, six themes were identified, which are outlined below with data extracts.
Service users suggested that prior to having contact with the IDVA, they were confused and uncertain about how to protect themselves from domestic violence. This is exemplified by the following two respondents:
You can’t do anything or say anything, otherwise the situation will get worse.
You don’t know what’s out there, you don’t know what you need, when something like this happens it knocks you for six really right off the tracks.
Respondents talked about the difficulties involved in seeking assistance from family or friends:
You don’t talk about these things with friends, you just don’t do it.
It’s embarrassing, they’ve told you but you haven’t listened and so you can’t really go to them and say ‘Yes, you were right.’
Feelings of social isolation were especially prominent in the accounts of women who lived in more isolated locations. Some of these individuals were reluctant to approach services for help, due to fear that they might become recognised as victims of domestic violence:
In [names large city] if you go somewhere you can ask, you don’t know them, they don’t know you. Here, if you go to [names hospital], you’re talking to your neighbour or your neighbour’s friend or someone you might see in the street next week, so it’s not that easy to bring it up, to ask or to say yes.
Respondents were equally reluctant to approach the police for help. Many talked about how their experiences of reporting previous incidents of domestic violence acted as a disincentive to report new offences. Many respondents identified that there were problems with the way in which cases were dealt with after a perpetrator was arrested, but most commonly service users were negative about the delays they had experienced, the lack of information they had received, and the bail and sentencing decisions that had been made in the police station or court. For example:
To be honest there’s no point reporting stuff because, so yeah they come and speak with him and if you’re lucky they take him away, but two, three hours later he’s back, he’s told them some sob story and that he’s sobered up so right, bail.
In the context of this initial confusion and isolation, the assertive approach adopted by an IDVA was considered to be crucial:
It’s what I needed, it’s what I would have liked earlier – someone to come round and see [name] and the boys and be able to say ‘I think this is what you need.’
If you wanted help I knew it was there, but sometimes you don’t know what you want, you need to be told, pointed in the right direction. It’s also, you don’t want to tell the story over and over again, you don’t want to, so you leave it, prefer to avoid it. So you get lots of cards, but you don’t want to ring them. [IDVA] rang me, so she made it easy for me to talk, she came to me.
Respondents talked about being reluctant or unable to initiate contact with services themselves, but being pleased when an IDVA contacted them:
I got a letter from [IDVA] and she then phoned up, I think, it was out of the blue because that hadn’t happened before, when I got the letter I just thought another letter, didn’t really read it to be honest, but then she phoned up and we talked and she came to my house. That helped.
Service users portrayed themselves as lacking the motivation and energy to contact services themselves. Clearly they wanted help, but were either pessimistic about receiving any help, lacked confidence, or did not have the energy to act as a result of their experiences of abuse:
Looking back it’s interesting because sometimes you know you should just pick up the phone, but then you think ‘Oh God! I’ve got to go through it all again’, it’s exhausting and you think ‘Oh no.’
Frequently the respondents did not drive. and were in any case distant from the agencies that might be able to provide them with services. In the following extract the respondent refers to problems with contacting the police, and how having an IDVA involved with her case helped her to access information. She also talks about how this involvement may have dissuaded her from dropping criminal justice proceedings:
She contacted me once a week, but if there were other questions, if she said she’d contact the police because the other problem is you have an arresting officer but if they go out on annual leave, you’re left phoning around really finding info, they send you round the houses and you get all upset and emotional about it and you think ‘Is it worth pursuing?’ and you feel the injustice of it, but [IDVA] stepped in, and she wrote as well and asked questions.
Many service users talked about facing problems not only with childcare but also with money and housing. Like the following respondent, they talked about difficulties in accessing help in these areas:
I didn’t know who to turn to, where to go, around here there’s nothing like citizen’s advice or anything like that, no one to talk to about things. [XXXX] is like OK only 35 minutes away by car, but I don’t drive and I’ve got the kids, what am I supposed to do?
In this context, the IDVA was valued because they were able to provide emotional support and information that the service users felt they would not otherwise receive. In the following extract, one respondent talks about both of these aspects of the IDVA’s role:
She just seemed concerned about me, asking me how I was, how the children were, telling me she was there for me and about the help she could give, making sure I had all the right things in place. ... I don’t know if it was her that arranged for the bobby van [a police ‘resource van’ which examines and then installs locks and other security measures in victims’ homes] to come round but it did, at my mum’s where I lived originally, but then at my own house when I went home, she told me all about what was happening and got in touch when things happened.
The following respondent talks about the impact that the support she received had on her self-confidence:
But what she does is she reassures you and just lets you know about things, it helps you get your confidence back because you know where you are.
None of the respondents talked about needing to be referred for counselling or emotional support. However, as the previous extract illustrates, many of them experienced the IDVA as being a therapeutic influence in their lives. In the following extract the respondent describes her relationship with the IDVA as having a therapeutic element:
To be honest I don’t know how I would have survived without her, she was helping, listening, a support for me really, someone I could phone anytime and you never got the impression she wasn’t interested or wanted you off the phone, you could unload it all.
As well as emotional support, service users valued the advice that they received from the IDVA. In the following extract, a respondent describes the way in which an IDVA was able to advise her on issues related to the abuser having contact with her children after he had been arrested and bailed by the police:
He assaulted me and I needed help really support because I didn’t know anything about him not seeing the children, social services, didn’t know anything really if the house was safe, she was someone for me to talk to, to delegate between me and the police.
The respondents did not talk about being signposted on to relevant agencies for help in these areas. Rather, they spoke about IDVAs providing a service in this area themselves:
She helped me fill out grant [form] and stuff to do up the house, helped me get money because as soon as he left I had no money or anything and no one to turn to, so she helped me sort out things like benefits, housing, everything really.
A key issue for the service users was that the IDVA had helped them to talk through their choices, rather than promoting any particular outcome:
We had an incident a few weeks ago and everyone around me were saying ‘Just leave, just leave’, but I didn’t want to, not really supportive, but [the IDVA] wasn’t like that, she wasn’t telling me what I should do, just, obviously she said her bit, but if I didn’t want to she was happy to work with that.
The non-judgemental attitude of the IDVA seemed to promote trust between her and the service users:
You could say anything, I think to be honest if I had have said I’ve decided to go back to him she wouldn’t have tried to persuade me not to, just talked it over with me, you know, are you sure and stuff.
The IDVA’s involvement with, but independence from, the police was also valued:
It’s someone you can contact who is not the police, they’re not scary – the police, they’re not, but they are too because they are [a] law enforcement person and if you go to them, that’s it, whereas she was that like of in-between person I could talk to if there was a problem brewing.
A number of service users talked about feeling safer as a result of the IDVA’s involvement:
The most important thing is for someone to talk to who can make you feel safe, more than that really to make you safer you know like with bail and stuff.
Several service users gave accounts of the IDVA being able to work with the police to ensure that bail restrictions were in place to protect the victim after their abuser had appeared in court. When asked to expand on how the IDVA made her feel safer, one respondent suggested that it was through reassurance and practical actions to make her safe:
She was really supportive, letting me know like with his bail conditions and everything the police weren’t really quick to phonemeor anything, but [the IDVA] was on the ball, he turned up at my house at midnight but the police didn’t do anything about it, so [the IDVA] was on the ball with that and asked why wasn’t anything done about it, she was on the phone telling them, so next morning, he was there again the next morning, when I phoned the police were round straight away almost.
In a number of instances the service that the IDVA provided had been crucial in protecting women and their children from further abuse. In several interviews, service users talked about being given false, self serving information by their abuser, which they were able to discard by checking it out with the IDVA:
He told me the court had said it was my fault and he should be allowed to see the children, and I wasn’t sure and [the IDVA] was telling me where I stood on that, that the court wouldn’t have said that and hadn’t said that.
Some service users talked about a lack of clarity with regard to roles and responsibilities between the IDVA and others who provided them with services. In relation to this, one service user stated:
At times I didn’t know who was doing what, I was having people phonemeonmymobile and leaving messages after court, and I didn’t know who was who if I’m honest.
Another service user commented on the confusion that arose from having too many people involved in her life:
It was baffling. I was in touch with Women’s Aid, the police, prosecution, I didn’t know who was doing what or what was happening, it’s a little confusing, so at the beginning I didn’t know, people would ring and say ‘It’s such and such here’ and I’d have to think ‘Who’s that?’
The service users indicated that the IDVA primarily provided a telephone-based service. Commenting on this, almost all of the respondents suggested that a more personal face-to-face approach would have been valued:
[The IDVA] has been very supportive on the phone, but she’s based in [names town], which is 45 minutes drive plus in one direction from here, and I live 45 minutes the other way, so it has really just been on the phone.
Support was at a distance, not [the IDVA’s] fault, she would like to have done more, but wasn’t able to.
Another respondent commented:
[The IDVA] couldn’t go to court, sometimes she can get involved and sometimes she can’t, my nearest court is 15 minutes away, but for [the IDVA] it’s like 2 1/ 2 hours away.
Exchanging information over the phone could be problematic, as the following respondent makes clear:
She was like in [name of town] two hours away really, but it was fine I could speak with her on the phone and more importantly she got things done, it was sometimes a problem though if you needed to give information and stuff you know you had to get it photocopied and sent to her rather than just hand it over if you were in an office.
Service users valued the IDVA’s assertive approach to making initial contact, and they understood that itwas more likely to engage them with services. This finding is of interest because, over the past few decades, the philosophical and practical focus of agencies that provide services to female victims of domestic violence has been to act in response to a request from the victim. The IDVA service was offered more assertively and, according to the findings of this study,was valued and understood as being more appropriate because the fear and confusion that victims of domestic violence often experienced made them reluctant to seek help themselves.
The IDVA service helped service users with a wide range of problems, and provided themwith significant ‘listening-ear’ support. Very little reference was made to any signposting to other agencies. This may have been because there were particular difficulties with implementing an effective domestic violence strategy in the area. This is the case in many rural areas (Grama, 2000), and in the area that was being studied other support, advocacy and advisory services were especially poorly developed. As a result, the IDVA was often the only source of help or support cited as being available to victims of domestic violence.
Providing a personal and thereby enhanced level of service clearly had implications, one of which was that significant time was devoted to individual cases, so most of the contact between the IDVA and service users had to take place by phone. In this regard, although the telephone contact that was provided was perceived as useful, most of the service users regretted the absence of more face-to-face interaction. One explanation for this may be that telephone contact is routinely perceived as less meaningful than face-toface encounters because it is comparatively less ‘rich in social cues’ (Rutter, 1987, p. 38). Nevertheless, the comments thatwere made about the IDVA service and about IDVAs show that significant relationships did develop between service providers and users, even in the absence of face-to-face interaction. Overall, the service users remained positive about the involvement of the IDVAs in their lives, and about the telephone services that had been provided.
There was some evidence of confusion about the IDVA’s role and, at times, role duplication. A number of service users described being confused about who was contacting them. Interestingly, although an IDVA would be involved in giving general support, guidance and advice to service users on matters such as childcare, finance and housing, this did not appear to compromise their independence. The IDVA service was enthusiastically endorsed by the service users, and IDVAs were understood to be independent of any other agency.
This research has some obvious limitations due to the non-randomised way in which respondents were recruited, and the small sample size involved. However, as Guest et al (2006) found, in some circumstances theme saturation can be achieved with small numbers of participants. There were consistencies within and between the accounts provided by service users, and the research is supported by and supports aspects of the existing literature. Consequently, it is possible to draw some tentative conclusions about the IDVA service being offered. Where similarities exist between research contexts, Shapiro (2007) suggests that there is an argument for concluding that some of the findings in one context may be transferable to another context. Therefore some of the conclusions reached here may be transferable to other rural contexts.
The main conclusion to be drawn from this study is that the IDVA service was valued by service users and perceived by them as having made a significant contribution to making them feel safe and able to adjust to life after experiencing domestic violence. If this was to be translated into fewer instances of victims returning to violent relationships, considerable health, criminal justice and social care savings would be likely to accrue. Previous research suggests that funding an IDVA is a ‘spend to save’ endeavour. This study lends support to that conclusion, not least because none of the nine service users who were interviewed for this research reported that they had experienced any repeated acts of violence since they became involved with the IDVA.
A further conclusion is that providing an IDVA service may be of particular importance in some rural areas. As this research has highlighted, victims of domestic abuse who live in rural areas may feel especially visible, and so may find it particularly difficult to approach statutory or voluntary services for help. Consequently, they may be more isolated from relevant services and agencies, unable to access them, or find that key information is less easy to access than in urban areas because important functions are dependent on a smaller pool of staff. In this context, for a victim of domestic violence an IDVA may be their only source of support and advice.
Although the Coordinated Action Against Domestic Abuse (2008) definition of an IDVA role places emphasis on the IDVA’s signposting function, in practice it is the case that, in some rural areas, IDVAs may find themselves unable to refer victims to other agencies. Rather than ignoring this issue and putting IDVAs in the invidious position of having to witness and ignore unmet needs, or meet such needs surreptitiously, attention could be paid to reviewing the terms of reference for an IDVA service in rural contexts. In this study it was found IDVAs were involved in giving emotional support and housing and financial advice, and that this was valued and did not appear to compromise the IDVA’s independent status. Formalising such functions in some contexts would ensure that IDVAs are appropriately trained and supported.
The final conclusion of this research is that, during austere times, one way of continuing to meet needs could be through developing further a telephonebased service. Notwithstanding the preference for faceto- face contact that was expressed by service users, telephone-based advocacy services may potentially be a cost-effective mechanism for providing individuals with access to advocacy and support, especially in rural communities, when money is scarce. The finding that the respondents valued telephone-based services is consistent with recent evidence that telephone support may be no less effective than face-to-face support, despite the fact that the latter is more highly valued (Munroe et al, 2000; Goelitz, 2003). Research (for the most part international) does suggest a number of advantages to telephone support, which can in some cases, and especially where alternatives are lacking, compare favourably with face-to-face services (Roberts et al, 1995; Samarel et al, 2002).