The health-systems response to violence against women

Health practitioners' perceptions of structural barriers to the identification of intimate partner abuse: a qualitative meta-synthesis

BACKGROUND

Health care practitioners (HCPs) play a critical role in identifying and responding to intimate partner abuse (IPA). Despite this, studies consistently demonstrate a range of barriers that prevent HCPs from effectively identifying and responding to IPA. These barriers can occur at the individual level or at a broader systems or organisational level. In this article, we report the findings of a meta-synthesis of qualitative studies focused on HCPs' perceptions of the structural or organisational barriers to IPA identification.

METHODS

Seven databases were searched to identify English-language studies published between 2012 and 2020 that used qualitative methods to explore the perspectives of HCPs in relation to structural or organisational barriers to identifying IPA. Two reviewers independently screened the articles. Findings from the included studies were analysed using Thomas and Hardin's method of using a thematic synthesis and critiqued using the Critical Appraisal Skills Program tool for qualitative studies and the methodological component of the GRADE-CERQual.

RESULTS

Forty-three studies conducted in 22 countries informed the review. Eleven HCP settings were represented. Three themes were developed that described the structural barriers experienced by HCPs: The environment works against us (limited time with patients, lack of privacy); Trying to tackle the problem on my own (lack of management support and a health system that fails to provide adequate training, policies and response protocols and resources), Societal beliefs enable us to blame the victim (normalisation of IPA, only presents in certain types of women, women will lie or are not reliable).

CONCLUSION

This meta-synthesis highlights the need for structural change to address these barriers. These include changing health systems to enable more time and to improve privacy, training, policies, and referral protocols. On a broader level IPA in health systems is currently not seen as a priority in terms of global burden of disease, mortality and morbidity and community attitudes need to address blaming the victim.

Experiences of Violence Against Lesbian and Bisexual Women in Brazil

BACKGROUND

Lesbophobia and biphobia are manifestations of homophobic violence directed at lesbian and bisexual women that results in daily violation of rights and social exclusion.

AIM

To describe experiences of the violence against lesbian and bisexual women in Brazil.

METHODS

Sequential mixed methods study was carried out in 2 stages. In the first one, quantitative, an electronic questionnaire was applied to women from all regions, with questions about sociodemographic characteristics, self-identification and lesbophobic and biphobic events. In the second one, qualitative, lesbian, and bisexual women were interviewed face to face about the violence suffered.

OUTCOMES

The chi-square test was applied to compare violence against lesbian and bisexual women (type of violence, place of aggression, gender and age range of the aggressor, bond with the aggressor, repetition of violence, and denunciation of violence) and the content analysis for qualitative data (main categories of analysis were events of violence, denunciation, and consequences of violence).

RESULTS

The report of violence was present in 65% of the answers. There was a predominance of psychological violence (39.8%), in the public environment (63%), practiced by men (73.2%), by strangers (66.2%) and repeatedly (82%). Lesbian women, compared to bisexuals, were more prone to violence in the public environment (59.5% vs 39.5%) and with repetition (84.3% vs 60.6%). The narratives explained intimidating experiences in the family environment (insults, threat of suicide or homicide and false imprisonment) and public (harassment, beatings, and rape). Discriminatory attitudes, insults, and refusal of service in restaurants and bars were recurrent.

CLINICAL IMPLICATIONS

The data provide information that can serve to improve policy initiatives to reduce these episodes.

STRENGTHS AND LIMITATIONS

This is the first study of mixed methods, with national coverage, on lesbophobia and biphobia events in Brazil. Future studies should include women underrepresented in this research as trans women, non-white, less educated, and from the most distant regions of the country.

CONCLUSION

Lesbophobic or biphobic event has harmful repercussions for multiple aspects of these women's lives, including mental health. Rufino AC, Filho CEWBdeC, Madeiro A. Experiences of Violence Against Lesbian and Bisexual Women in Brazil. Sex Med 2021;XX:XXXXXX.

Dentistry responding to domestic violence and abuse: a dental, practice-based intervention and a feasibility study for a cluster randomised trial

Objectives Assess the feasibility of using the Identification and Referral to Improve Safety (IRIS) intervention in a general dental practice setting and evaluating it using a cluster randomised trial design. IRIS is currently used in general medical practices to aid recognition and support referral into specialist support of adults presenting with injuries and other presenting factors that might have resulted from domestic violence and abuse. Also, to explore the feasibility of a cluster randomised trial design to evaluate the adapted IRIS.Design Feasibility study for a cluster randomised trial of a practice-based intervention.Setting Greater Manchester general dental practices.Results It was feasible to adapt the IRIS intervention used in general medical practices to general dental practices in terms of training the clinical team and establishing a direct referral pathway to a designated advocate educator. General dental practices were keen to adopt the intervention, discuss with patients when presented with the opportunity and utilise the referral pathway. However, we could not use practice IT software prompts and data collection as for general practitioners because there is no unified dental IT system and because coding in dentistry for diagnoses, procedures and outcomes is not developed in the UK.Conclusion While it was feasible to adapt elements of the IRIS intervention to general dental practice and there was general acceptability, we did not have enough empirical data to plan a definitive cluster randomised trial design to evaluate the IRIS-dentistry intervention within general dental practices.

Social workers' perspectives on barriers and facilitators in responding to intimate partner violence in primary health care in Spain

OBJECTIVE

To identify the barriers and facilitators of managing intimate partner violence (IPV) cases, from the perspective of primary health care (PHC) social workers.

METHOD

Qualitative study through interviews with 14 social workers working in PHC centres in Spain. A thematic analysis approach was applied to identify barriers and facilitators according to the Tanahashi model.

RESULTS

The barriers identified by social workers in providing effective coverage to women suffering from IPV included insufficient practical training, a lack of knowledge from women on social workers' roles, a lack of teamwork, and excess IPV case referrals from other professionals to social workers. The identified facilitators were the existence of electronic protocols and good practices including therapeutic support groups and holistic intervention approaches.

CONCLUSIONS

An excess of referrals to social workers of identified IPV cases following consultation by other members of the PHC team, alongside the lack of interdisciplinary teamwork, does not enable a comprehensive and holistic approach to this problem. Compulsory, practical, and interdisciplinary training in IPV for all PHC professionals and students must be a priority for health agencies and universities in order to facilitate a comprehensive and quality approach for all women suffering from IPV.

Innovations in implementing a health systems response to violence against women in 3 tertiary hospitals of Maharashtra India: Improving provider capacity and facility readiness

Background

Violence against women [VAW] is an urgent public health issue and health care providers [HCPs] are in a unique position to respond to such violence within a multi-sectoral health system response. In 2013, the World Health Organization (WHO) published clinical and policy guidelines (henceforth - the Guidelines) for responding to intimate partner violence and sexual violence against women. In this practical implementation report, we describe the adaptation of the Guidelines to train HCPs to respond to violence against women in tertiary health facilities in Maharashtra, India.

Methods

We describe the strategies employed to adapt and implement the Guidelines, including participatory methods to identify and address HCPs' motivations and the barriers they face in providing care for women subjected to violence. The adaptation is built on querying health-systems level enablers and obstacles, as well as individual HCPs' perspectives on content and delivery of training and service delivery.

Results

The training component of the intervention was delivered in a manner that included creating ownership among health managers who became champions for other health care providers; joint training across cadres to have clear roles, responsibilities and division of labour; and generating critical reflections about how gender power dynamics influence women's experience of violence and their health. The health systems strengthening activities included establishment of standard operating procedures [SOPs] for management of VAW and strengthening referrals to other services.

Conclusions

In this intervention, standard training delivery was enhanced through participatory, joint and reflexive methods to generate critical reflection about gender, power and its influence on health outcomes. Training was combined with health system readiness activities to create an enabling environment. The lessons learned from this case study can be utilized to scale-up response in other levels of health facilities and states in India, as well as other LMIC contexts.

Plain language summary

Violence against women affects millions of women globally. Health care providers may be able to support women in various ways, and finding ways to train and support health care providers in low and middle-income countries to provide high-quality care to women affected by violence is an urgent need. The WHO developed Clinical and Policy Guidelines in 2013, which provide guidance on how to improve health systems response to violence against women. We developed and implemented a series of interventions, including training of health care providers and innovations in service delivery, to implement the WHO guidelines for responding to violence against women in 3 tertiary hospitals of Maharashtra, India. The nascent published literature on health systems approaches to addressing violence against women in low and middle-income countries focuses on the impact of these interventions. This practical implementation report focuses on the interventions themselves, describes the processes of developing and adapting the intervention, and thus provides important insights for donors, policy-makers and researchers.

Perceptions of primary health care workers regarding violence against women

Abstract Objective: To identify the perceptions of Primary Health Care workers regarding Violence Against Women. Method: Qualitative, exploratory, descriptive study addressing 23 health professionals working in three Health Centers in Praia, Cape Verde, Africa. Semi-structured interviews were held via videoconference in November and December 2020. Data were treated according to thematic analysis. Results: Three categories emerged: violence against women restricted to physical aggression; violence as a phenomenon resulting from financial dependency; and victim blaming. Conclusion: The reductionist view of violence, as limited to physical harm, associated with financial dependency and victim blaming helps to unveil perceptions that ground the practice of health workers with women victims of violence and can support the planning of continuous education provided in Primary Health Care services.

Design and Evaluation of a Curriculum on Intimate Partner Violence for Medical Students in an Emergency Medicine Clerkship

PURPOSE

Intimate partner violence (IPV) is a widespread public health issue that is relevant to all areas of medicine. Patients who suffer from IPV often contact the health care system via the emergency department, making this a particularly important but too often overlooked issue in this setting. Education on IPV varies in medical schools and emergency medicine (EM) educational programs, and evidence suggests that a barrier to assessing for IPV is a lack of adequate training of clinicians. In this study, we sought to design, implement and evaluate the efficacy of a curriculum on IPV geared towards medical students on an EM clerkship.

METHODS

We assembled a multi-disciplinary team of EM education faculty, a resident content expert on IPV, and social workers to design a two-part curriculum that was administered to medical students on an EM clerkship. The curriculum involved a 20-minute narrated slide presentation viewed asynchronously, followed by a 1-hour case-based discussion session. The curriculum was evaluated using a 13-item self-assessment survey on knowledge, comfort level and skill in managing victims of IPV, administered electronically before and after the curriculum. Survey results were compared pre- and post-curriculum using Wilcoxon signed-rank test.

RESULTS

Thirty-four students completed the curriculum and 26 completed both the pre and post self-assessment surveys. A statistically significant improvement in knowledge, comfort level and skills was observed in 11 of the 13 survey elements.

CONCLUSION

Based on the self-assessment survey results, this curriculum was well received and successfully increased participants' comfort, knowledge and skill level regarding assessment of patients for IPV. This is a focused and feasible curriculum that can be easily incorporated into an EM clerkship to provide effective education on a relevant but often overlooked topic.

Strengthening Health Systems' Response to Violence Against Women in Three Tertiary Health Facilities of Maharashtra

Background

Domestic violence is known to have a significant impact on the health of women. Despite this, the health system in India is not equipped to respond to women facing violence. This can be attributed to limited information on how the evidence-based guidelines can be implemented in resource-constrained settings. To fill this gap, implementation research was carried out in three tertiary medical teaching hospitals in Maharashtra.

Methods

The project was implemented in the OBGY, Medicine and Emergency department of a medical college and a district hospital in the state of Maharashtra. The intervention included consultation with key providers of three departments and a 5 day training of trainers on VAW. The trainers conducted 2 day onsite training for the health care providers. System-level interventions included the development of SOPs, IEC material, documentation format and identifying places for a private consultation. The research involved a pre- and post-test to assess change in KAP of providers after training, analysis of documentation register and interviews with trained providers and survivors.

Results

Findings indicate a significant change in knowledge, attitude and practice of the providers. Documentation registers introduced in the facility departments showed 531 women facing violence were responded by providers in 9 months. In 59% of cases, the provider suspected violence based on presenting health complaints, indicating the success of the capacity building programmes in the development of skills to identify VAW signs and symptoms, as well as provide psychological support to women/girls. There was a high acceptability of intervention among providers. Survivors also recognised the usefulness of health care facility-based support services for violence.

Conclusion

A multi-component intervention comprising of building capacity of providers and facility readiness is feasible to implement in low- and middle-income countries (LMIC) and can strengthen health systems' response to VAW.

"One of the most important subjects for a healthcare worker": Cross-sectional student evaluation of family violence best practice response curriculum

Family violence can affect the health and well-being of victim-survivors. Nurses and other healthcare providers are well placed to respond to family violence, yet evidence shows that nurses have limited knowledge of family violence and students are unprepared for this work. The objective of this study was to evaluate a pilot of the subject Family Violence Best Practice Response for undergraduate nurses and other healthcare students at an Australian university. The study used a cross-sectional pre-posttest design. Survey instruments included a modified version of the Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS) tool and the World Health Organization Curriculum evaluation tools. Sixty-four students enrolled in the pilot. Participants made significant improvements in their feelings of preparedness to complete family violence work and in their perceived knowledge across a range of clinical practices and knowledge domains. Qualitative data showed students enjoyed the subject and gained valuable knowledge of how to inquire and validate disclosures. Healthcare professionals should receive training and be ready and able to identify and sensitively respond to victim-survivors of family violence when they enter the workforce.

Effects of e-learning on the support of midwives and nurses to perinatal women suffering from intimate partner violence: A randomized controlled trial

AIMS

To examine the effects of e-learning on intimate partner violence (IPV) knowledge, preparatory/reinforcing behaviors for supporting IPV victims, and IPV screening of midwives and nurses.

METHODS

Participants were randomly assigned to the intervention group (IG: e-learning) and control group (CG: no e-learning). The primary outcome was the mean change in knowledge score. The secondary outcomes were the mean number of types of practiced preparatory/reinforcing behaviors and the proportions of participants who practice screening. Unpaired t tests were performed in intention-to-treat analysis.

RESULTS

Of the 88 participants, 45 were randomly assigned to the IG and 43 to the CG. For the post-1-test, the IG had a mean change in the knowledge score of 8.5 points with a significant difference from the 1.4 points in the CG (mean difference [MD] 7.1, 95% CI [4.1, 10.1]). The mean change between the pre-test and the post-2-test was significantly larger in the IG (7.9 points) than in the CG (1.3 points) (MD 6.6, 95% CI [3.3, 9.9]). The mean number of types of practiced behaviors at the post-1-test and post-2-test was significantly higher in the IG than in the CG (MD 1.4, 95% CI [0.1, 2.8]). There was no significant difference in the proportions of participants who practice screening between the two groups postintervention.

CONCLUSIONS

The e-learning effectively improved knowledge and promoted preparatory/reinforcing behaviors.

A qualitative content analysis of nurses' perceptions about readiness to manage intimate partner violence

AIMS

To explore the perceptions of nurses on the factors that influence their readiness to manage intimate partner violence (IPV) in Spain.

DESIGN

Qualitative content analysis based on data from six different regions in Spain (Murcia, Region of Valencia, Castile and Leon, Cantabria, Catalonia, Aragon) collected between 2014 and 2016.

METHODS

37 personal interviews were carried out with nurses from 27 primary health care (PHC) centres and 10 hospitals. We followed the consolidated criteria for reporting qualitative research guidelines. Qualitative content analysis was supported by Atlas.ti and OpenCode.

RESULTS

The results are organised into four categories corresponding to (1) acknowledging IPV as a health issue. An ongoing process; (2) the Spanish healthcare system and PHC service: a favourable space to address IPV although with some limitations; (3) nurses as a key figure for IPV in coordinated care and (4) factors involved in nurses' autonomy in their response to IPV, with their respective subcategories.

CONCLUSION

In practice, nurses perceive responding to IPV as a personal choice, despite the institutional mandate to address IPV as a health issue. There is a need to increase continuous training and ensure IPV is included in the curriculum in university nursing undergraduate degrees, by disseminating the existing IPV protocols. Furthermore, coordination between healthcare professionals needs to be improved in terms of all levels of care and with other institutions.

Health Professionals' Experiences of Providing Trauma-Informed Care in Acute Psychiatric Inpatient Settings: A Scoping Review

BACKGROUND

Trauma-informed care is increasingly recognized as the ideal model of care for acute psychiatric inpatient units; however, it continues to be a challenge to implement. The aims of this review are (1) to synthesize the research exploring health professionals' experiences of providing trauma-informed care in acute psychiatric inpatient settings and (2) to examine these experiences through a gender lens, particularly relating to gender-based violence. This research will provide additional insights to facilitate implementation of trauma-informed care in acute psychiatric inpatient care.

METHOD

A comprehensive scoping review methodology was adopted. English-language, peer-reviewed articles published between January 1998 and March 2018 were identified from seven databases. Inclusion criteria included a qualitative or mixed-method study design.

RESULTS

Eight full-text articles were found. This review highlights the importance for health professionals to have a reflective environment and a multilayered level of collaboration to adopt trauma-informed care. However, negative attitudes toward female consumers and inconsistent implementation strategies continue to hold back implementation of trauma-informed care in acute psychiatric inpatient units. Overall, limited consideration for gendered issues and gender-based violence in the implementation of trauma-informed care in acute psychiatric inpatient settings was found.

CONCLUSION AND IMPLICATIONS

There is a lack of research on health professionals' experiences of providing trauma-informed care in acute psychiatric inpatient units, with even less research considerating gender-based violence. We argue that more research is needed to gain a better understanding of the experience of health professionals from acute psychiatric inpatient settings to inform future implementation of trauma-informed care.

Gay, Bisexual, and Queer Men's Attitudes and Understandings of Intimate Partner Violence and Sexual Assault

Gay, bisexual, and queer (GBQ) men experience significant rates of intimate partner violence (IPV) and sexual assault (SA); however, there is limited research into their attitudes and understandings of IPV and SA. This article presents the findings of a 2018 survey of 895 GBQ men currently residing in Australia, focused on their views and experiences of healthy and unhealthy relationships. The survey included quantitative and open-ended qualitative questions. The findings presented in this article are primarily descriptive, with cross-tabulations and t tests to demonstrate significant differences between groups and correlational statistics to outline associations between variables. Qualitative data were coded under broad themes. The study found a considerable proportion of men (three in five) identified that they had experienced an unhealthy or abusive relationship in the past, with minimal disclosure to police or health services. Men with a history of partner abuse or violence were more likely to report binge drinking or drug use and more likely to know a friend who had abused his partner. 40% of the sample had witnessed an incident of relationship violence between GBQ men, and two-thirds intervened in the violence in some way. The findings of this study underscore the need to engage GBQ men in discussions about respectful relationships, address the role of alcohol and drugs in GBQ socialization and relationships, and provide bystander skills for men to intervene in situations of aggression or violence between men in relationships.

The role of champions in leading domestic violence and abuse practice improvement in healthcare: a scoping review

AIM

To describe and synthesize evidence for champions of domestic violence practice improvement in healthcare and highlight implications for leadership and nurse management.

BACKGROUND

Globally, healthcare leaders have been tasked with improving service responses to domestic violence. Evidencing the role of champions, and how managers may harness champions in improving responses to domestic violence, is an important factor in successfully leading change in this field.

EVALUATION

A scoping review was conducted using four electronic databases (Proquest, PubMed, Medline and PsycINFO).

KEY ISSUES

Eleven studies were included. Champion characteristics, roles, and factors influencing their impact were distilled. Barriers to the success of champions were identified as were four aspects of the champion role: mentor and expert advice; communication and engagement; strategic advocacy, coordination and project leadership; personal and emotional support.

CONCLUSIONS

The review highlighted that champions involved in domestic violence project implementation have unique aspect to their role, along with characteristics reported in the broader champion literature. As an emerging field, there is evidence that domestic violence champions play an important role in mentoring and supporting healthcare workers to effectively change their practice.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers and leaders need to understand the champion construct and the roles that champions enact to generate domestic violence and abuse system and practice change. Further research is required to provide guidance.

Integrated system responses for families impacted by violence: a scoping review protocol

INTRODUCTION

The impacts of violence have a significant effect on health and well-being, particularly for women and children. Violence within families is widely recognised as a complex problem constituted by constantly interacting and evolving social, economic, health and cultural elements. Calls for integrated services have arisen from growing understanding about the implications of this complexity, which suggest family violence and solutions to it are generated endogenously from the reflexive nonlinear interactions of system agents. Despite these calls for integration, services designed to support families impacted by violence and the systems that design and fund them are often responsive only to one part of the problem and might not pay attention to agent interactions and their adaptive reflexivity. This paper outlines a scoping protocol to explore how integrated approaches to family violence are conceptualised in current literature, with innovative use of a complexity theory lens.

METHOD

Our scoping review protocol follows the framework outlined by Arksey and O'Malley and refined by Levac. It searches 6 databases, 3 journals and 10 websites using keywords to capture the notion of integration and a complex adaptive system, namely the participant (system agents), concept (system agent interaction) and the context (family violence). Selection criteria require the articles to be written in English, have full-text article available, and were published after 2010. Items selected also need to be evidence based showing interaction between system agents. Applying complexity theory, sensitises us to the reflexive patterns of interaction between system elements and routine ways of interacting.

ETHICS AND DISSEMINATION

The nature of this review means that ethics approval is not required. Findings will be disseminated via academic publications, conferences and discussions with policy decision-makers. The findings will be used to develop a plan for stakeholder consultation to share and validate learnings and inform future research.

Determinants of Gender-Based Violence and Its Physiological Effects Among Women in 12 African Countries

Goals 3 and 5 of the United Nations Sustainable Development Goals are to promote good health and well-being and to achieve gender equality, respectively. To successfully move toward these goals in the area of gender equality, there is the need to understand the underlying legislative or laws that protect women and girls from all forms of domestic violence (DV), including gender-based violence (GBV). The cardinal objective of this study, therefore, was to examine the risk factors of GBV and the physiological effects of GBV. To date, few studies have quantified the relationship between laws on DV and the incidence of DV/GBV. This article fills that gap by using Demographic and Health Surveys (DHS) data of 12 African countries. We applied multivariate logistic regression to estimate the association of the absence of laws on DV, men dominant power, history of violence, alcohol consumption, women's attitude toward men's violence perpetration, and decision-making power with the scores of GBV and physiological effects of GBV. Group Kruskal-Wallis Rank test was used to determine the variation of the two outcomes among the 12 countries. Results show significant disparities in the score of GBV, H test ₍₁₁₎ = 168,217, p < .001, and score of physiological effects, H test ₍₁₁₎ = 122,127, p < .001, among the 12 countries. Specifically, Ghana, Namibia, Rwanda, Mozambique, Zimbabwe, Malawi, Sierra Leone, and Togo reported the highest physiological effect of GBV. Presence of DV laws, male dominance, alcohol consumption, history of abuse, and women empowerment predict GBV and the physiological effect of GBV. Thus, building strong legal frameworks against all forms of DV and empowering women may reduce the incidence of GBV and physiological effects of GBV for all African women.

Intimate Partner Violence: Barriers to Action and Opportunities for Intervention Among Health Care Providers in São Paulo, Brazil

Health care providers (HCPs) who directly interact with women play a critical role in intimate partner violence (IPV) prevention and response. The aim of this study was to identify the structural and interpersonal barriers to IPV response among HCPs working in public health clinics in Santo André, Brazil. Eligible participants included all HCPs providing direct care to individuals at three public health clinics. Participants self-administered an adapted Knowledge, Attitudes, and Practices survey on IPV. Data were analyzed using Epi Info 7 and SAS 9.4. 114 HCPs completed surveys. Less than half of HCPs (41%, n = 34) reported ever having asked a woman about abuse in the past year. HCPs who perceived fewer barriers were more likely to report asking about IPV. The top three reported barriers to asking women about IPV included the following: few opportunities for one-on-one interaction (77%, n = 65), a lack of privacy (71%, n = 60), and fear of offending women (71%, n = 60). Fewer providers who perceived the barriers of lack of privacy asked about IPV (50.8%, n = 33 compared with 84.2%, n = 16; p < .05); less providers who perceived few opportunities for private patient interactions asked about IPV (48.3%, n = 29 compared with 75.0%, n = 18; p < .05). Our results support the need for a systems approach of institution-wide reforms altering the health care environment and avoiding missed opportunities in IPV screening and referring women to appropriate resources or care. Two of the most frequently reported barriers to asking IPV were structural in nature, pointing to the need for policies that protect privacy and confidentiality. Within the Brazilian context, our research highlights the role of HCPs in the design and implementation of IPV interventions that both strengthen health systems and enable providers to address IPV.

Knowledge, attitudes and practices of health care providers trained in responding to violence against women: a pre- and post-intervention study

BACKGROUND

Violence against women is a serious public health concern, and is highly prevalent globally, including in India. Health-care providers [HCPs] can play an important role in addressing and reducing negative consequences of violence against women. We implemented a pre-post intervention study of HCP training in three tertiary care facilities in Maharashtra, India.

METHODS

The study used a pre-post intervention design with assessment of HCPs' (n = 201) knowledge, attitudes, perceived preparedness and practice at three time points: before training, after training and at 6 months follow- up.

RESULTS

Total median score of knowledge about common signs and symptoms of violence (8.89 vs, 10.00), attitudes towards acceptability of violence (9.05 vs. 10.00), individual (6.74 vs. 10.00) and system level preparedness (6.11 vs. 8.14) improved from pre to post- training. The generalized estimating equation [GEE] model, adjusted for age, sex, site and department, showed an improvement in knowledge, attitudes and preparedness post- training. The change from pre to 6 months follow- up was not significant for attitude.

CONCLUSIONS

This package of interventions, including training of HCPs, improved HCPs' knowledge, attitudes and practices, yet changes in attitudes and preparedness did not sustain over time. This study indicates feasibility and positive influence of a multi-component intervention to improve HCP readiness to respond to violence against women in a low-resource setting. Future phases of intervention development include adapting this intervention package for primary and secondary health facilities in this context, and future research should assess these interventions using a rigorous experimental design. Finally, these results can be used to advocate for multi-layered, systems-based approaches to strengthening health response to violence against women.

The professional relationship forms the base: Swedish child health care nurses' experiences of encountering mothers exposed to intimate partner violence

PURPOSE

This study aimed to explore child health care nurses' clinical experiences from encounters with mothers exposed to intimate partner violence (IPV), as little research has explored this topic.

METHOD

Nine child health care nurses from two Swedish regions were interviewed. The interviews were analysed using thematic analysis.

RESULTS

The narratives depicted the nurses' strong commitment to, and professional relationship with, the exposed mothers. The experience of working as a nurse and having encountered IPV in clinical practice made the nurses more confident, which impacted their performance and attitude towards this topic. The ability to uphold the professional relationship was threatened by lack of support and interprofessional collaborations.

CONCLUSIONS

The professional relationship was central to the encounters, yet could impose an emotional burden on the nurses. While the nurses wanted to improve their knowledge of the process around the mother and child, they were happy to pass the primary responsibility over to other professionals. The findings highlight the challenge in establishing sustainable support for nurses, and building a transparent collaboration process between the health care sector and the social services, serving the well-being and safety of the mother and child.

Threads of Practice: Enhanced Maternal and Child Health Nurses Working With Women Experiencing Family Violence

Family violence is a serious public health issue with significant health consequences for women and children. Enhanced Maternal and Child Health nurses (EMCH) in Victoria, Australia, work with women experiencing family violence; however, scholarly examination of the clinical work of nurses has not occurred. This qualitative study explored how EMCH nurses work with women experiencing abuse, describing the personal and professional challenges for nurses undertaking family violence work. Twenty-five nurses participated in semi-structured interviews. Using interpretive description methodology has enabled an insight into nurses' family violence work. Threads of practice identified included (1) Validating/Reframing; (2) Non-judgmental support/Safeguarding and (3) Following/Leading. The nurses highlighted the diversity of experience for women experiencing abuse and nurses' roles in family violence nurse practice. The research contributes to understanding how EMCH nurses traverse threads of practice to support women experiencing family violence.

Vulnerability Factors among Women Victimized by Intimate Partner Violence and the Presence of Children

This study aimed to a) examine the presence of children in relation to victim vulnerability factors and assessed risk for intimate partner violence (IPV) re-victimization, and b) examine the police response, in terms of risk management, in IPV cases with and without children, respectively. Data from a sample of 1407 women who had reported IPV victimization to the Swedish police was analyzed. The material consisted of risk assessments conducted by the police using the Swedish version of the Brief Spousal Assault Form for the Evaluation of Risk (B-SAFER) checklist, as well as the recommended risk management strategies. A series of chi-square tests of independence revealed that women with and without children, respectively, displayed different vulnerability factors to different extents. Women with children expressed more extreme fear of the perpetrator and were more likely to have an unsafe living situation, whereas women without children displayed more inconsistent attitudes or behaviors and health problems. However, binary logistic regression analyses showed that the victim vulnerability factors that were most strongly associated with an elevated risk rating for IPV re-victimization were generally the same for both groups of victims. Finally, the presence of children was related to a higher risk rating for imminent IPV re-victimization and to recommendations of more than standard levels of risk management strategies. The results indicate that the Swedish police consider the presence of children in relation to a victim's risk for re-victimization as well as in terms of recommended risk management strategies.

Mapping the health systems response to violence against women: key learnings from five LMIC settings (2015-2020)

Background

Violence against women (VAW) is a global challenge, and the health sector is a key entry point for survivors to receive care. The World Health Organization adopted an earlier framework for health systems response to survivors. However, documentation on the programmatic rollout of health system response to violence against women is lacking in low and middle-income countries. This paper studies the programmatic roll out of the health systems response across select five low- and middle-income countries (LMIC) and identifies key learnings.

Methods

We selected five LMIC settings with recent or active programming on national-level health system response to VAW from 2015 to 2020. We synthesized publicly available data and program reports according to the components of the WHO Health Systems Framework. The countries selected are Bangladesh, Brazil, Nepal, Rwanda, and Sri Lanka.

Results

One-stop centers were found to be the dominant model of care located in hospitals in four countries. Each setting has implemented in-service training as key to addressing provider knowledge, attitudes and practice; however, significant gaps remain in addressing frequent staff turnover, provision of training at scale, and documentation of the impact of training. The health system protocols for VAW address sexual violence but do not uniformly include clinical and health policy responses for emotional or economic violence. Providing privacy to survivors within health facilities was a universal challenge.

Conclusion

Significant efforts have been made to address provider attitudes towards provision of care and to protocolize delivery of care to survivors, primarily through one-stop centers. Further improvements can be made in data collection on training impact on provider attitudes and practices, in provider identification of VAW survivors, and in prioritization of VAW within health system budgeting, staffing, and political priorities. Primary health facilities need to provide first-line support for survivors to avoid delays in response to all forms of VAW as well as for secondary prevention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01499-8.

Validity of the ACTS intimate partner violence screen in antenatal care: a cross sectional study

Background

Intimate partner violence (IPV) is a major public health problem with harmful consequences. In Australia, there is no national standard screening tool and screening practice is variable across states. The objectives of this study were to assess in the antenatal healthcare setting: i) the validity of a new IPV brief screening tool and ii) women’s preference for screening response format, screening frequency and comfort level.

Methods

One thousand sixty-seven antenatal patients in a major metropolitan Victorian hospital in Australia completed a paper-based, self-administered survey. The survey included four screening items about whether they were Afraid/Controlled/Threatened/Slapped or physically hurt (ACTS) by a partner or ex-partner in the last 12 months; and the Composite Abuse Scale (reference standard). The ACTS screen was presented firstly with a binary yes/no response format and then with a five-point ordinal frequency format from ‘never’ (0) to ‘very frequently’ (4). The main outcome measures were test statistics of the four-item ACTS screening tool (sensitivity, specificity, predictive values, and area under the curve) against the reference standard and women’s screening preferences.

Results

Twelve-month IPV prevalence varied depending on the ACTS response format with 8% (83) positive on ACTS yes/no format, 12.8% (133) positive on ACTS ordinal frequency format and 10.5% (108) on the reference Composite Abuse Scale. Overall, the ACTS screening tool demonstrated clinical utility for the ordinal frequency format (AUC, 0.80; 95% CI = 0.76 to 0.85) and the binary yes/no format (AUC, 0.74, 95% CI = 0.69 to 0.79). The frequency scale (66%) had greater sensitivity than the yes/no scale (51%). The positive and negative predictive values were 56 and 96% for the frequency scale and 68 and 95% for the yes/no scale. Specificity was high regardless of screening question response options. Half (53%) of the women categorised as abused preferred the yes/no scale. Around half of the women (48%, 472) thought health care providers should ask pregnant women about IPV at every visit.

Conclusions

The four-item ACTS tool (using the frequency scale and a cut-off of one on any item) is recommended for written self-administered screening of women to identify those experiencing IPV to enable first-line response and follow-up.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11781-x.

Longitudinal trends in screening males and females for intimate partner violence as part of a systemic multi-specialty health system intervention

Objective

To assess intimate partner violence screening for males and females in a health system that underwent a systemic intervention to improve survivor identification and response. Electronic health record data from 13 clinics were accessed for February of 2017, 2018, and 2019 to calculate screening rates and positive screening rates for intimate partner violence by clinic and sex-race groups (n  =  11,693 non-Hispanic White females; n  =  4318 Other females; n  =  9184 non-Hispanic White males; n  =  3441 Other males). Linear mixed effects models were used to examine whether screening rates differed significantly over time and by sex-race group.

Results

Screening rates were 31% for the first 2 years and 16% for 2019. Screening rates varied greatly by clinic. Dermatology, psychiatry, and otolaryngology clinics had average or above screening rates all 3 years. Differences in screening rates across sex-race groups were minimal. Average positive screen rates were 1.3%, 0.4%, and 2.6% in 2017, 2018, and 2019, respectively, with psychiatry having the highest positive screen rate. Positive screen rates were highest for non-Hispanic White females (3.5%). Universal screening in this health system was not yielding survivors comparable to existing estimates among clinic-based populations. Other identification approaches require testing to effectively identify survivors within the health sector.

Intimate partner violence against women. Does violence decrease after the entry of the alleged offender into the criminal justice system?

Intimate partner violence (IPV) is simultaneously assumed as a serious crime and a major public health issue, having recurrences as one of its main characteristics and, consequently, re-entries of some alleged offenders in the criminal justice system (CJS). The main goal of this study is to assess if in cases of female victims of IPV, violence decreases after the first entry of the alleged offender in the CJS. A retrospective study was performed based on the analysis of police reports of alleged cases of IPV during a 4-year period. The final sample (n = 1 488) was divided into two groups according to the number of entries in the CJS (single or multiple) followed by a comparative approach. Results suggest that violence decreases after the first entry of alleged offenders in the CJS. Re-entries were found in only 15.5% of the cases but they were accountable for 3.3 times more crimes on average. Besides, victims of recidivism presented more injuries and required more medical care. Thus, a small group of alleged offenders seems to be more violent and accountable for most of the IPV crimes registered in the CJS suggesting that regardless of legal sanctions aiming to deter violence, these measures may not be enough for a certain group of offenders. This study sustains the need for a predictive model to quantify the risk of repeated IPV cases within the Portuguese population.

Managing maternal and child health nurses undertaking family violence work in Australia: A qualitative study

AIM

To explore the experience of nurse managers managing maternal and child health nurses undertaking family violence work in Victoria, Australia.

BACKGROUND

Health care practitioners' ability to address violence against women is strengthened by health service systems that include effective staff management and leadership. Maternal and child health nurses work with women experiencing abuse; however, their support by the health system and their managers has not been examined.

METHOD

Semi-structured interviews with 12 nurse managers in 2019-2020 explored how they supervised and managed nurses. The data were analysed using reflexive thematic analysis.

RESULTS

We identified three themes-(a) managing the service: being resourceful; (b) supporting nurses' emotional safety; and (c) hitting the ground running: the demands on the manager.

CONCLUSION

Inadequate support for nurse managers undermines workplace well-being and role satisfaction, impacting the safety and supervision of nurses doing family violence work.

IMPLICATIONS FOR NURSING MANAGEMENT

An integrated family violence systems approach must include improved training and support for nurse managers to enable reflective practice and ensure effective support for nurses working with women experiencing abuse.

Gameplay, learning and emotions in the board game Violets: cinema & action in combating violence against women

The board game Violets: cinema and action in combating violence against women was developed prioritising the liberating features of play to offer a setting for struggles to secure citizenship. The objective of the article was to examine the gameplay of Violets as regards players' understanding of the rules and engagement, and the game's mechanics and design; and to evaluate gameplay, emotions and learning comparatively as dimensions of play. This mixed method study proceeded in stages: a) perfecting gameplay: a workshop with 12 experts, usability tests with 33 participants and content analysis; and b) evaluating play: questionnaires for 78 participants and non-parametric Mann-Whitney U-test comparing groups of variables. Agreement among participants on aspects of gameplay was high. The group of gameplay variables returned values equal to those of the learning group; both differed significantly from the group for emotions felt while playing. In Violets, the interweave of gameplay with the formative, learning components set up a challenging, affective, symbolic field where players' imagination, interaction, tension and interest were expressed during play.

Intimate Partner Violence and the Role of Breast Imaging Centers

Intimate partner violence (IPV) is defined as physical violence, sexual violence, stalking, or psychological harm by a current or former intimate partner. In the United States, one in three women will experience a form of IPV in their lifetime. Screening for IPV at breast imaging centers provides an important opportunity to identify and assist affected women. Breast imaging centers provide a private environment where passive and active IPV screening methods can be employed. In addition, when obtaining a mammogram or breast ultrasound, the patient's upper chest is exposed, which could demonstrate patterns of abuse. This article discusses the need for IPV screening, via both passive and active methods, and implementation steps for breast imaging centers.

Intimate partner violence is associated with poorer maternal mental health and breastfeeding practices in Bangladesh

Exposure to intimate partner violence (IPV) can have profound adverse consequences on maternal and child health. This study aimed to: (1) identify factors associated with IPV during pregnancy and postpartum in Bangladesh; and (2) assess the associations between IPV and maternal mental health and breastfeeding practices. We used data from a cross-sectional survey of 2000 mothers with children <6 months in four districts in Bangladesh. We applied multivariable logistic regression models to examine factors associated with IPV and structural equation modelling to assess the inter-relationships between IPV, maternal common mental disorders (CMD, measured by Self-reporting Questionnaire ≥7) and breastfeeding practices. Overall, 49.7% of mothers experienced violence during the last 12 months and 28% of mothers had high levels of CMD. Only 54% of women reported early initiation of breastfeeding and 64% reported exclusive breastfeeding. Women were more likely to experience IPV if living in food-insecure households, being of low socio-economic status, having low autonomy or experiencing inequality in education compared with husbands (OR ranged from 1.6 to 2.8). Women exposed to IPV were 2–2.3 times more likely to suffer from high levels of CMD and 28–34% less likely to breastfeed their babies exclusively. The indirect path (the indirect effects of IPV on breastfeeding through CMD) through maternal CMD accounted for 14% of the relationship between IPV on breastfeeding practice. In conclusion, IPV is pervasive in Bangladesh and is linked to increased risks of CMD and poor breastfeeding practices. Integrating effective interventions to mitigate IPV, along with routine maternal and child health services and involving men in counselling services, could help both to reduce exposure to IPV among women and to contribute to better health outcomes for women and children.

Spatial analysis of female intentional homicides

OBJECTIVE

To analyze the characteristics and spatial distribution of female intentional homicides, according to the regional health offices, in a state in the Northeast Region of Brazil.

METHOD

This is an ecological study that had the municipality and regional health offices as units of analysis and used data from the Brazilian Mortality Information System. Mortality rates were calculated and smoothed by the local empirical Bayesian method. To identify the existence of spatial autocorrelation, the Moran's index was used.

RESULTS

A total of 1,144 homicides were reported, with an average rate of 6.2/100,000 women. For all regional health offices, the 10-39 age group, black race/skin color, and single marital status prevailed. The homicides took place in public spaces. The days of the week with the highest records were Saturday and Sunday and the months of the year December, January, February, and June. The global Moran's index was 0.6 (p = 0.01). Clusters of municipalities with high homicide rates were identified in regional health offices III and IV.

CONCLUSIONS

The homicide victims were young, black, and single. The spatial analysis found critical areas of homicide occurrence, which are a priority for actions to prevent violence against women.

Categories and health impacts of intimate partner violence in the World Health Organization multi-country study on women's health and domestic violence

BACKGROUND

Intimate partner violence (IPV) damages health and is costly to families and society. Individuals experience different forms and combinations of IPV; better understanding of the respective health effects of these can help develop differentiated responses. This study explores the associations of different categories of IPV on women's mental and physical health.

METHODS

Using data from the World Health Organization (WHO) Multi-Country Study on Women's Health and Domestic Violence, multilevel mixed effects logistic regression modelling was used to analyse associations between categories of abuse (physical IPV alone, psychological IPV alone, sexual IPV alone, combined physical and psychological IPV, and combined sexual with psychological and/or physical IPV) with measures of physical and mental health, including self-reported symptoms, suicidal thoughts and attempts, and nights in hospital.

RESULTS

Countries varied in prevalence of different categories of IPV. All categories of IPV were associated with poorer health outcomes; the two combined abuse categories were the most damaging. The most common category was combined abuse involving sexual IPV, which was associated with the poorest health [attempted suicide: odds ratio (OR): 10.78, 95% confidence interval (CI) 8.37-13.89, thoughts of suicide: 8.47, 7.03-10.02, memory loss: 2.93, 2.41-3.56]. Combined psychological and physical IPV was associated with the next poorest outcomes (attempted suicide: 5.67, 4.23-7.60, thoughts of suicide: 4.41, 3.63-5.37, memory loss: 2.33, 1.88-2.87-).

CONCLUSIONS

Understanding the prevalence and health impact of different forms and categories of IPV is crucial to risk assessment, tailoring responses to individuals and planning services. Previous analyses that focused on singular forms of IPV likely underestimated the more harmful impacts of combined forms of abuse.

#WhyIDidntReport: Women Speak Out About Sexual Assault on Twitter

BACKGROUND

In September 2018, Dr. Christine Blasey Ford accused then-nominee to the U.S. Supreme Court Brett Kavanaugh of sexual assault. When then-U.S. President Donald Trump questioned her credibility on Twitter, sexual assault survivors began tweeting their reasons for not reporting using the hashtag #WhyIDidntReport. This study examined how these posts were discussed on Twitter and to what extent the tweets fit within levels of the Social Ecological Model (SEM).

METHOD

This study used quantitative content analysis to code 1,000 tweets with #WhyIDidntReport for violence type, reasons for not reporting, and SEM levels.

RESULTS

Overall, 68.7% of posts mentioned a specific reason for not reporting; of these, 24.1% referred to the perpetrator being in a position of power, 36.3% feared not being believed, and 20.6% mentioned that others invalidated the assault. In addition, 47.6% mentioned a specific form of violence. Within the SEM, 47.6% referred to individual, 52.6% to relational, 43.2% to community, and 21.7% to societal reasons for not reporting.

CONCLUSION

Reading social media content allows healthcare providers to directly discover how survivors talk about their experiences, priorities in the care environment, and how to support a patient-centered and trauma-informed approach.

IMPLICATIONS

Understanding reasons people do not report sexual assault is critical for healthcare professionals to engage patients in open, honest screening and intervention efforts.

Personal barriers to addressing intimate partner abuse: a qualitative meta-synthesis of healthcare practitioners' experiences

BACKGROUND

Healthcare practitioners (HCPs) play a crucial role in recognising, responding to, and supporting female patients experiencing intimate partner abuse (IPA). However, research consistently identifies barriers they perceive prevent them from doing this work effectively. These barriers can be system-based (e.g. lack of time or training) or personal/individual. This review of qualitative evidence aims to synthesise the personal barriers that impact HCPs' responses to IPA.

METHODS

Five databases were searched in March 2020. Studies needed to utilise qualitative methods for both data collection and analysis and be published between 2010 and 2020 in order to qualify for inclusion; however, we considered any type of healthcare setting in any country. Article screening, data extraction and methodological appraisal using a modified version of the Critical Appraisal Skills Program checklist for qualitative studies were undertaken by at least two independent reviewers. Data analysis drew on Thomas and Harden's thematic synthesis approach.

RESULTS

Twenty-nine studies conducted in 20 countries informed the final review. A variety of HCPs and settings were represented. Three themes were developed that describe the personal barriers experienced by HCPs: I can't interfere (which describes the belief that IPA is a "private matter" and HCPs' fears of causing harm by intervening); I don't have control (highlighting HCPs' frustration when women do not follow their advice); and I won't take responsibility (which illuminates beliefs that addressing IPA should be someone else's job).

CONCLUSION

This review highlights the need for training to address personal issues in addition to structural or organisational barriers. Education and training for HCPs needs to: encourage reflection on their own values to reinforce their commitment to addressing IPA; teach HCPs to relinquish the need to control outcomes so that they can adopt an advocacy approach; and support HCPs' trust in the critical role they can play in responding. Future research should explore effective ways to do this within the context of complex healthcare organisations.

Violent Motherhood: Prevalence and Factors Affecting Violence Against Pregnant Women in India

Violence against women is widely recognized as a serious public health problem in the world. Especially violence against pregnant women has more severe health consequences for both women and child. The objective of this study is to examine the prevalence and factors affecting violence during pregnancy in India. Data from the National Family Health Survey (NFHS)-4 are used to analyze this study. NFHS is a series of demographic health surveys conducted in India. Information on violence against pregnant women was collected for the first time in NFHS-4. Univariate and multivariate analyses are used to show the factors affecting violence during pregnancy. Study results reveal that the prevalence of violence varied among states from 0.5% to 9%, and women in South India were at a greater risk of abuse during pregnancy than that of women in other parts of India. Women with no education, women in poor household, women having three and more children, and women from rural area are at greater risk of being victims of violence during motherhood. Effective strategies such as responsive health care system, effective implementation of legal measures, and educating and engaging men in preventing violence are urgently needed.

Transformative or Functional Justice? Examining the Role of Health Care Institutions in Responding to Violence Against Women in India

With the growing salience of ideas and reforms concerning women's human rights and gender equality, violence against women (VAW) has received heightened policy attention. Recent global calls for ending VAW identify health care systems as having a crucial role in a multisector response to tackle this social injustice. Scholars emphasize the transformative potential of such response in its ability to not only address the varied health consequences but also prevent future recurrence by enabling wider access to support and justice. This wider consensus on the role of health systems, however, demands stronger empirical basis. This article reports findings from an exploratory research developed around the core question: What are the perceived strengths and challenges confronting health systems in offering a comprehensive response to VAW in India? Drawing on site visits, observations, and interviews with front-line staff and program managers of an integrated intervention to tackle violence in Kerala and nongovernment organisation staff in Delhi and Mumbai, the article presents its historical context and key barriers to effective implementation. While promising in terms of outreach and incremental changes in attitudes, barriers include deficits in infrastructure and institutional practices that reinforce inequities in gender-power relations, hostile attitudes, and limited capacities of health workforce to tackle the complex and diverse needs of women experiencing abuse. Locating these experiences in relation to other models rooted in feminist approach, I argue how conventional intervention models of provisioning fail to challenge institutional contexts and structural inequalities that underpin violence and compound vulnerabilities experienced by women, thereby serving a functional response. Health systems are social institutions embedded in prevailing gender norms and power relations that must be tackled alongside addressing imminent needs of women victims of abuse. To this end, feminist approaches to counselling and relational perspectives to social justice can strengthen responsiveness (and transformative potential) of integrated sector-wide interventions.

Training healthcare providers to respond to intimate partner violence against women

BACKGROUND

Intimate partner violence (IPV) includes any violence (physical, sexual or psychological/emotional) by a current or former partner. This review reflects the current understanding of IPV as a profoundly gendered issue, perpetrated most often by men against women. IPV may result in substantial physical and mental health impacts for survivors. Women affected by IPV are more likely to have contact with healthcare providers (HCPs) (e.g. nurses, doctors, midwives), even though women often do not disclose the violence. Training HCPs on IPV, including how to respond to survivors of IPV, is an important intervention to improve HCPs' knowledge, attitudes and practice, and subsequently the care and health outcomes for IPV survivors.

OBJECTIVES

To assess the effectiveness of training programmes that seek to improve HCPs' identification of and response to IPV against women, compared to no intervention, wait-list, placebo or training as usual.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and seven other databases up to June 2020. We also searched two clinical trials registries and relevant websites. In addition, we contacted primary authors of included studies to ask if they knew of any relevant studies not identified in the search. We evaluated the reference lists of all included studies and systematic reviews for inclusion. We applied no restrictions by search dates or language.

SELECTION CRITERIA

All randomised and quasi-randomised controlled trials comparing IPV training or educational programmes for HCPs compared with no training, wait-list, training as usual, placebo, or a sub-component of the intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures outlined by Cochrane. Two review authors independently assessed studies for eligibility, undertook data extraction and assessed risks of bias. Where possible, we synthesised the effects of IPV training in a meta-analysis. Other analyses were synthesised in a narrative manner. We assessed evidence certainty using the GRADE approach.

MAIN RESULTS

We included 19 trials involving 1662 participants. Three-quarters of all studies were conducted in the USA, with single studies from Australia, Iran, Mexico, Turkey and the Netherlands. Twelve trials compared IPV training versus no training, and seven trials compared the effects of IPV training to training as usual or a sub-component of the intervention in the comparison group, or both. Study participants included 618 medical staff/students, 460 nurses/students, 348 dentists/students, 161 counsellors or psychologists/students, 70 midwives and 5 social workers. Studies were heterogeneous and varied across training content delivered, pedagogy and time to follow-up (immediately post training to 24 months). The risk of bias assessment highlighted unclear reporting across many areas of bias. The GRADE assessment of the studies found that the certainty of the evidence for the primary outcomes was low to very low, with studies often reporting on perceived or self-reported outcomes rather than actual HCPs' practices or outcomes for women. Eleven of the 19 included studies received some form of research grant funding to complete the research. Within 12 months post-intervention, the evidence suggests that compared to no intervention, wait-list or placebo, IPV training: · may improve HCPs' attitudes towards IPV survivors (standardised mean difference (SMD) 0.71, 95% CI 0.39 to 1.03; 8 studies, 641 participants; low-certainty evidence); · may have a large effect on HCPs' self-perceived readiness to respond to IPV survivors, although the evidence was uncertain (SMD 2.44, 95% CI 1.51 to 3.37; 6 studies, 487 participants; very low-certainty evidence); · may have a large effect on HCPs' knowledge of IPV, although the evidence was uncertain (SMD 6.56, 95% CI 2.49 to 10.63; 3 studies, 239 participants; very low-certainty evidence); · may make little to no difference to HCPs' referral practices of women to support agencies, although this is based on only one study (with 49 clinics) assessed to be very low certainty; · has an uncertain effect on HCPs' response behaviours (based on two studies of very low certainty), with one trial (with 27 participants) reporting that trained HCPs were more likely to successfully provide advice on safety planning during their interactions with standardised patients, and the other study (with 49 clinics) reporting no clear impact on safety planning practices; · may improve identification of IPV at six months post-training (RR 4.54, 95% CI 2.5 to 8.09) as in one study (with 54 participants), although three studies (with 48 participants) reported little to no effects of training on identification or documentation of IPV, or both. No studies assessed the impact of training HCPs on the mental health of women survivors of IPV compared to no intervention, wait-list or placebo. When IPV training was compared to training as usual or a sub-component of the intervention, or both, no clear effects were seen on HCPs' attitudes/beliefs, safety planning, and referral to services or mental health outcomes for women. Inconsistent results were seen for HCPs' readiness to respond (improvements in two out of three studies) and HCPs' IPV knowledge (improved in two out of four studies). One study found that IPV training improved HCPs' validation responses. No adverse IPV-related events were reported in any of the studies identified in this review.

AUTHORS' CONCLUSIONS

Overall, IPV training for HCPs may be effective for outcomes that are precursors to behaviour change. There is some, albeit weak evidence that IPV training may improve HCPs' attitudes towards IPV. Training may also improve IPV knowledge and HCPs' self-perceived readiness to respond to those affected by IPV, although we are not certain about this evidence. Although supportive evidence is weak and inconsistent, training may improve HCPs' actual responses, including the use of safety planning, identification and documentation of IPV in women's case histories. The sustained effect of training on these outcomes beyond 12 months is undetermined. Our confidence in these findings is reduced by the substantial level of heterogeneity across studies and the unclear risk of bias around randomisation and blinding of participants, as well as high risk of bias from attrition in many studies. Further research is needed that overcomes these limitations, as well as assesses the impacts of IPV training on HCPs' behavioral outcomes and the well-being of women survivors of IPV.

Sexist Myths Emergency Healthcare Professionals and Factors Associated with the Detection of Intimate Partner Violence in Women

This study analysed the capacity of emergency physicians and nurses working in the city of Granada (Spain) to respond to intimate partner violence (IPV) against women, and the mediating role of certain factors and opinions towards certain sexist myths in the detection of cases. This is a cross-sectional study employing the physician readiness to manage intimate partner violence survey (PREMIS) between October 2020 and January 2021, with 164 surveys analysed. Descriptive and analytical statistics were applied, designing three multivariate regression models by considering opinions about different sexist myths. Odds ratios and 95% confidence intervals (CIs) were considered for the detection of cases. In the past six months, 34.8% of professionals reported that they had identified some cases of IPV, particularly physicians (OR = 2.47, 95% CI = 1.14–5.16; OR = 2.65, 95% CI = 1.26–5.56). Those who did not express opinions towards sexist myths related to the understanding of the victim or the consideration of alcohol/drug abuse as the main causes of violence and showed a greater probability of detecting a case (NS) (OR = 1.26 and OR = 1.65, respectively). In order to confirm the indicia found, further research is required, although there tends to be a common opinion towards the certain sexual myth of emergency department professionals not having an influence on IPV against women.

PRimary care rEsponse to domestic violence and abuse in the COvid-19 panDEmic (PRECODE): protocol of a rapid mixed-methods study in the UK

Background

The implementation of lockdowns in the UK during the COVID-19 pandemic resulted in a system switch to remote primary care consulting at the same time as the incidence of domestic violence and abuse (DVA) increased. Lockdown-specific barriers to disclosure of DVA reduced the opportunity for DVA detection and referral.

The PRECODE (PRimary care rEsponse to domestic violence and abuse in the COvid-19 panDEmic) study will comprise quantitative analysis of the impact of the pandemic on referrals from IRIS (Identification and Referral to Improve Safety) trained general practices to DVA agencies in the UK and qualitative analysis of the experiences of clinicians responding to patients affected by DVA and adaptations they have made transitioning to remote DVA training and patient support.

Methods/Design

Using a rapid mixed method design, PRECODE will explore and explain the dynamics of DVA referrals and support before and during the pandemic on a national scale using qualitative data and over four years of referrals time series data.

We will undertake interrupted-time series and non-linear regression analysis, including sensitivity analyses, on time series of referrals to DVA services from routinely collected data to evaluate the impact of the pandemic and associated lockdowns on referrals to the IRIS Programme, and analyse key determinants associated with changes in referrals.

We will also conduct an interview- and observation-based qualitative study to understand the variation, relevance and feasibility of primary care responses to DVA before and during the pandemic and its aftermath.

The triangulation of quantitative and qualitative findings using rapid analysis and synthesis will enable the articulation of multiscale trends in primary care responses to DVA and complex mechanisms by which these responses have changed during the pandemic.

Discussion

Our findings will inform the implementation of remote primary care and DVA service responses as services re-configure. Understanding the adaptation of clinical and service responses to DVA during the pandemic is crucial for the development of evidence-based, effective remote support and referral beyond the pandemic.

Trial registration

PRECODE is an observational epidemiologic study, not an intervention evaluation or trial. We will not be reporting results of an intervention on human participants.

Characteristics of violence against women in Kairouan, Tunisia, in 2017

Violence against women represents a serious concern worldwide. In Tunisia, despite an advanced legislative framework, we still receive women victims of violence. This survey aimed to characterize the demographic and clinical profile of women victims of violence in Kairouan, central Tunisia. This survey was designed as a cross-sectional study. It concerned women victims of violence over 18 years old, consulting the emergency department of the University Hospital of Kairouan during 3 months in 2017. We defined violence against women according to the Tunisian protection of gender discrimination law. This survey included 100 Tunisian victims of violence; their median age was 35 (ranging from 18 to 59 years old). This study showed that 58% of victims, CI95% [48.3%, 67.6%], were illiterate or had only a primary level education and that 90%, CI95% [84.1%, 95.8%], had a low or middle socioeconomic level. The Intimate Partner Violence was about 70% among all cases, CI 95% [61.0%, 78.9%]. Most aggressive partners were young (aged between 39 and 51 years old). The most affected part of the body was the face (76%, CI 95% [67.6%, 84.3%]). Alcohol consumption was the primary risk factor of violence in 29.6% of cases, CI95% [20.0%, 37.9%]. Other risk factors were the occupational instability, conflicts with the family in-laws and infidelity. Violence against women remains widespread. Even strict legislations in Tunisia didn’t protect women sufficiently from different types of violence. It mostly happens within intimate relationships. Therefore, surveillance and early intervention controlling risk factors are extremely important.

Who is Being Screened for Intimate Partner Violence in Primary Care Settings? Secondary Data Analysis of a Cluster Randomised Trial

OBJECTIVES

To assess sociodemographic differences in postpartum women screened for intimate partner violence and who disclosed to their Maternal and Child Health nurses.

METHODS

Secondary analyses of survey data from women participating in a cluster randomised trial. The trial tested a nurse-designed, enhanced violence screening model-versus routine screening among eight community nurse clinics in Melbourne, Australia. Self-completion anonymous surveys were sent to all clinic attendees who had given birth in the previous eight months. We measured intimate partner violence with the Composite Abuse Scale and other sociodemographic variables. Multivariable logistic regression was used to analyse characteristics of screened versus unscreened women and those who did or did not disclose.

RESULTS

91 clinics (163 nurses) participated in the trial. 2621/10,472 (25%) women responded to the survey. Notable characteristics, such as level of intimate partner violence (AdjOR 1.14, CI 0.94-1.40), parity (AdjOR 1.13, CI 0.94-1.35), education (AdjOR 1.20 CI 0.91-1.58) and being born in Australia (AdjOR 0.94, CI 0.86-1.03) made no significant difference to screening. However, nurses were significantly less likely to screen women with a lower income than those with a higher one (AdjOR 0.59, CI 0.40-0.87) with a dose response relationship. Women on the lowest levels of income were significantly more likely to disclose abuse (AdjOR 3.06, CI 1.02-9.17), indicating missed opportunities for nurses to provide timely care.

CONCLUSIONS FOR PRACTICE

Despite being required to screen all women, nurses are almost twice as likely to screen more affluent women, who would be less likely to be experiencing or disclose intimate partner violence.

Barriers to responding to reproductive coercion and abuse among women presenting to Australian primary care

Background

Reproductive coercion and abuse is defined as any behaviour that seeks to control a woman’s reproductive autonomy. In Australia, women often access reproductive health care through a primary care clinician, however, little is known about clinicians’ experiences responding to reproductive coercion and abuse. This study aims to address this gap by exploring the barriers to responding to reproductive coercion and abuse in Australian primary care.

Methods

In this qualitative study, twenty-four primary care clinicians from diverse clinical settings in primary care across Australia were recruited to participate in a semi-structured interview. Data were analysed thematically.

Results

Through analysis, three themes were developed: It’s not even in the frame; which centred around clinicians lack of awareness around the issue. There’s not much we can do, where clinicians described a lack of confidence in responding correctly as well as a lack of services to refer on to. Lastly There’s no one to help us, explaining the disconnect between referral services and primary care as well as the impacts of lack of abortion on women experiencing reproductive coercion and abuse.

Conclusions

Clinicians expressed similar experiences of barriers to respond to reproductive coercion and abuse. Many clinicians felt ill-equipped to identify and respond to reproductive coercion and abuse. Some clinicians hadn’t received any formal training, others were trained but had nowhere to refer women. Further complicating responses was a lack of support from referral services. This study highlights the need for more training and a streamlined referral pathways for women who experience reproductive coercion and abuse, as well as better access to reproductive health services in rural areas.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06420-5.

Barriers and facilitators of disclosing domestic violence to the healthcare service: A systematic review of qualitative research

Domestic violence victims are in frequent contact with the healthcare service yet rarely disclose. Therefore, it is critical to understand victims' experiences and perceptions regarding disclosure in healthcare settings. The goal of this review is to provide an updated synthesis of qualitative research identifying barriers and facilitators, advice, and positive and negative outcomes of adult victims' disclosure of domestic violence to healthcare professionals (HCPs). A systematic search of PsychINFO, CINAHL and Web of Science was conducted in January 2018. Thirty-four eligible studies were identified, including 783 domestic violence victims (781 females). Formal quality assessment indicated variable study quality. Barriers of disclosure included negative HCPs attitudes, victims' perceptions of safety and concerns about the consequences of disclosing. Facilitators of disclosing included a positive relationship with the HCP, HCPs directly asking victims about abuse, and HCPs ensuring that the environment is safe and disclosure is confidential. Victims advised increased awareness of HCPs reactions to disclosure and avoiding mirroring their perpetrators minimization. HCPs were encouraged to engage in direct questioning and maintain a supportive and secure environment. Positive and negative outcomes of abuse were identified, such as being able to leave the abuser or, on the other hand, the victims' situation not changing. Our results indicate that barriers for disclosure of domestic violence in healthcare settings persist despite the widespread implementation of policies and guidelines to counter them. Based on these findings, we provide recommendations for clinical practice and future research to help improve disclosure in healthcare settings.

Responding to family violence: Variations in knowledge, confidence and skills across clinical professions in a large tertiary public hospital

Introduction

Healthcare workers play a vital role in assessing and appropriately responding to family violence. Discipline-specific differences in the readiness to respond have been indicated in the literature but no studies have directly compared multiple disciplines using the same measure. Given the imperative need for a hospital-wide, multidisciplinary approach to managing family violence, this study aimed to compare and contrast clinician perceived levels of knowledge, confidence and clinical readiness to manage disclosures of family violence across major professional groups in a tier 1, tertiary adult trauma hospital in Australia.

Methods

This prospective cross-sectional study implemented a brief questionnaire to explore self-reported knowledge, confidence and clinical skills in managing family violence. Data were analysed using non-parametric analyses. The Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines for observational research were followed in the reporting of this study.

Results

Significantly greater self-reported clinical skills, knowledge and confidence were found among social work clinicians relative to all other disciplines. By contrast, allied health clinicians reported the lowest levels of clinical knowledge, confidence and skills relative to other discipline areas. No significant differences were seen between nursing and medicine.

Conclusion

There are significant differences across clinical professional groupings in knowledge and confidence levels, and clinical skills in assisting patients experiencing family violence. The findings have implications for facilitating a hospital-wide, multidisciplinary response to assisting clients experiencing family violence.

Exploring the feasibility and acceptability of integrating screening for gender-based violence into HIV counselling and testing for adolescent girls and young women in Tanzania and South Africa

BACKGROUND

Gender-based violence (GBV) undermines HIV prevention and treatment cascades, particularly among women who report partner violence. Screening for violence during HIV testing, and prior to offering pre-exposure prophylaxis (PrEP) to HIV uninfected women, provides an opportunity to identify those at heightened HIV risk and greater potential for non-adherence or early discontinuation of PrEP. The paper describes our experience with offering integrated GBV screening and referral as part of HIV counselling and testing. This component was implemented within EMPOWER, a demonstration project offering combination HIV prevention, including daily oral PrEP, to young women in South Africa and Tanzania.

METHODS

Between February 2017 and March 2018, a process evaluation was conducted to explore views, experiences and practices of stakeholders (study participants and study clinical staff) during implementation of the GBV screening component. This article assesses the feasibility and acceptability of the approach from multiple stakeholder perspectives, drawing on counselling session observations (n = 10), in-depth interviews with participants aged 16-24 (n = 39) and clinical staff (n = 13), and notes from debriefings with counsellors. Study process data were also collected (e.g. number of women screened and referred). Following a thematic inductive approach, qualitative data were analysed using qualitative software (NVivo 11).

RESULTS

Findings show that 31% of young women screened positive for GBV and only 10% requested referrals. Overall, study participants accessing PrEP were amenable to being asked about violence during HIV risk assessment, as this offered the opportunity to find emotional relief and seek help, although a few found this traumatic. In both sites, the sensitive and empathetic approach of the staff helped mitigate distress of GBV disclosure. In general, the delivery of GBV screening in HCT proved to be feasible, provided that the basic principles of confidentiality, staff empathy, and absence of judgment were observed. However, uptake of linkage to further care remained low in both sites.

CONCLUSION

Most stakeholders found GBV screening acceptable and feasible. Key principles that should be in place for young women to be asked safely about GBV during HIV counselling and testing included respect for confidentiality, a youth-friendly and non-judgmental environment, and a functioning referral network.

Paramedics as a New Resource for Women Experiencing Intimate Partner Violence

Intimate partner violence (IPV) has a major impact on the health and well-being of women. The need for a coordinated response from health care professions encountering IPV patients is well established, and guidelines for individual health care professions are needed. Paramedics are believed to frequently encounter IPV patients, and this study aims to create a guideline to direct their response based on expert opinion. A clinical guideline for paramedics was created using current evidence and recommendations from health agencies. A panel of family violence researchers and service delivery experts such as physicians, family violence support agencies, and police commented on the guideline via a Policy Delphi Method to obtain consensus agreement. A total of 42 experts provided feedback over three rounds resulting in 100% consensus. Results include clinical indicators to recognize IPV patients in the prehospital environment, a description of how paramedics should discuss IPV with patients, recommended referral agencies and pathways, and appropriate documentation of case findings. This study has created the first comprehensive, consensus-based guideline for paramedics to recognize and refer IPV patients to care and support. The guideline could potentially be modified for use by ambulance services worldwide and can be used as the basis for building the capacity of paramedics to respond to IPV, which may lead to increased referrals to care and support.

Engaging with Uncertainty and Complexity: A Secondary Analysis of Primary Care Responses to Intimate Partner Violence

Complex problems generate uncertainty. The number and diversity of interactions between different health professionals, perspectives, and components of the problem makes predicting an outcome impossible. In effort to reduce the uncertainty of intimate partner violence interventions, health systems have developed standardized guidelines and protocols. This paper presents a secondary analysis of 17 New Zealand primary care professional narratives on intimate partner violence as a health issue. We conducted a complexity-informed content analysis of participant narratives to explore uncertainty in greater depth. This paper describes three ways primary care professionals interact with uncertainty: reducing uncertainty, realizing inherent uncertainty, and engaging with uncertainty. We found dynamic patterns of interaction between context and the experience of uncertainty shape possible response options. Primary care professionals that probed into uncertainty generated new understanding and opportunities to respond to intimate partner violence.

Perception of Women with Lived Experience of Domestic Violence and Abuse on the Involvement of the Dental Team in Supporting Adult Patients with Lived Experience of Domestic Abuse in England: A Pilot Study

While there is existing evidence highlighting the important roles of health care professionals and the health care system in supporting patients with lived experience of domestic violence and abuse (DVA), there is a dearth of knowledge on the perception of dental patients on the involvement of the dental team, as health care professionals, in supporting adult patients experiencing domestic abuse. Data were collected from 24 women withs lived experience of domestic abuse using mixed methodological approaches and analysed using relevant analytic techniques. Results from this pilot study show that patients want to be asked about their experience of domestic abuse. Although there were barriers to disclosing to the dentist, evidence from this pilot study highlights that the dental practice is an avenue that can be used for appropriately signposting patients to relevant services. Evidence from this pilot study contributes to the existing knowledge on the need to raise awareness among the patient population with lived experience of DVA that the dental team can support them. In addition, there is a need for on-going training to enhance the capacity of the dental team for appropriately supporting their adult patients with lived experience of DVA.

Violence against women: An observational study in an Italian emergency department

Violence against women is a pervasive phenomenon affecting one in three women aged ≥15 in the world that are more likely to visit an emergency department (ED) for the serious physical and psychological consequences of the abuse. The aim of this observational single-centre study is to describe the socio-demographic and clinical variables associated with violence against women. We enrolled 425 female patients who attended an Italian ED for trauma on 2019 and the patients' information was collected and analyzed with descriptive statistics. The average age of the patients was 41.5 (standard deviation = 14.2) years. 74.6% of the women were Italians, and 86.6% were of metropolitan origin. The reasons for the ED visit included aggression (67.5%), accidental trauma (29.0%) and unknown reasons (3.5%). Multivariate analysis confirmed that three factors were independently associated with violence: nationality (odds ratio [OR] = 0.27; 95% confidence interval [CI], 0.09-0.77), head/face/neck injuries (OR = 7.32; 95% CI, 3.76-14.27) and multiple injuries (OR = 8.52; 95% CI, 1.03-70.47). Age over 25 was a protective factor. The study confirmed that being a foreigner and having head/face/neck injuries or multiple injuries are associated with violence against women.