The health-systems response to violence against women

Service evaluation of an independent domestic violence advocate post in a children's hospital

Domestic violence and abuse (DVA) has detrimental effects on the health and well-being of children and young people exposed to it, whether they witness or experience it. The introduction of independent domestic violence advocates in UK hospitals has enhanced the safety of victims of DVA. In 2020-2021 an independent domestic violence advocate post was piloted at a children's hospital for one year, the advocate's role being to train hospital staff and support women who had experienced DVA. A service evaluation showed that the training and support provided by the independent domestic violence advocate had benefits for women, children and staff. It also confirmed that the commissioning of services for children exposed to DVA is often underfunded and overshadowed by the provision of support to adults.

Co-creating a global shared research agenda on violence against women in low- and middle-income countries

BACKGROUND

Despite a large growth in evidence on violence against women (VAW) over the last 25 years, VAW persists, as do gaps in the field's knowledge of how to prevent and respond to it. To ensure that research on VAW in low- and middle-income countries (LIMCs) is addressing the most significant gaps in knowledge, and to prioritise evidence needs to reduce VAW and better support victims/survivors, the Sexual Violence Research Initiative (SVRI) and Equality Institute (EQI) led a process of developing a global shared research agenda (GSRA) on VAW in LMICs.

METHODS

The GSRA was developed through a six-stage adaptation of the Child Health and Nutrition Research Initiative (CHNRI) method, which draws on the principle of the 'wisdom of the crowd'. These steps included: a review of the literature on VAW in LMICs and development of domains; the generation of research questions within four domains by an Advisory Group; the consolidation of research questions; scoring of research questions by a Global Expert Group and the Advisory Group according to three criteria (applicability, effectiveness and equity); consultation and validation of the findings with the Advisory Group; and wide dissemination of the findings.

RESULTS

The highest ranked research questions in the GSRA pertain to the domain of Intervention research, with some highly ranked questions also pertaining to the domain of Understanding VAW in its multiple forms. Questions under the other two domains, Improving existing interventions, and Methodological and measurement gaps, were not prioritised as highly by experts. There was strong consistency in top ranked research questions according to experts' characteristics, albeit with some important differences according to experts' gender, occupation and geographical location.

CONCLUSIONS

The GSRA findings suggest that currently the VAW field is shifting towards intervention research after several decades of building evidence on understanding VAW, including prevalence, drivers and impacts of violence. The findings also suggest a strong emphasis on under-served populations, and under-researched forms of VAW. Future priority setting exercises in LMICs that seek to decolonise knowledge should ensure that methodologies, and modalities of engagement, put diverse voices at the centre of engagement. Trial registration Not applicable.

Readiness of Exercise Physiologists, Physiotherapists and Other Allied Health Professionals to Respond to Gender-Based Violence: A Mixed-Methods Study

Experiencing gender-based violence (GBV) is associated with health conditions that are common indications for referral to exercise physiologists, physiotherapists and other allied health professionals (AHPs). The readiness of AHPs to identify and respond to GBV is currently unknown. This study aimed to determine the readiness of AHPs to respond to a person who had experienced GBV. Participants completed the modified Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS) and/or an interview. The AHPs felt underprepared, had low perceived knowledge and lacked confidence to respond to and support people who have experienced GBV, despite recognition of the importance and agreement of the relevance to AHPs' practice.

Healthcare and legal systems responses to coercive control: an embodied performance of one woman's experience

This paper uses a drama-based method to illustrate the responses of healthcare and legal systems to women experiencing coercive control. This approach involved writing a play using the first-person narrative voice of a victim-survivor. We presented the play at the Stop Domestic Violence Conference (Gold Coast, Australia) in 2021. The central character, 'Kate', provided an embodied performance that enabled the conference participants to see, feel and understand experiences of coercive control from a personal perspective. We followed the trajectory of coercive control from the beginning of an intimate relationship to the time of separation. We showed how the process of coercive control escalates from love bombing, reproductive coercion, isolation, and technology-facilitated abuse until a point of police intervention. As Kate told her story, the conference audience witnessed the barriers and challenges faced by survivors of coercive control, and the emotional, financial, and psychological impacts that are intensified in geographically remote environments. They watched Kate navigate health and other systems meant to help women experiencing domestic and family violence, but that ultimately failed to deliver. Finally, the drama-based approach allowed us to present a feminist embodiment of coercive control and an innovative method for communicating inter-disciplinary research findings on domestic abuse.

Resisting invisibility in healthcare responses to gender-based violence: a content analysis

Women and girls with disabilities are located at the intersections of patriarchal, ableist, and other structures of oppression that produce specific and heightened vulnerabilities to gender-based violence (GBV). Public health practitioners widely recognise the role of the healthcare sector in addressing GBV, however the role of the healthcare sector in addressing GBV must be questioned given ongoing barriers to healthcare access for people with disabilities. Grounded in an intersectional framework, I conducted a summative content analysis of GBV healthcare interventions to examine whether and how disability and intersectionality are mobilised in public health understanding of, and strategies to, address GBV. By bringing visibility to the ways in which silences construct and sustain the invisibility of women with disabilities and other social structures, I argue that GBV healthcare responses not only fail to provide care for women with disabilities across social locations, but they also risk reproducing understandings that devalue their lives.

'Atawhai': a primary care provider-led response to family violence in Aotearoa New Zealand

BACKGROUND

As a key determinant of ill-health, family violence is inadequately responded to within Aotearoa New Zealand health policy and practice. Without adequate system support, health professionals can often be unsure of what to do, or how to help. Developed in response to this system gap, 'Atawhai' aims to make it easier for primary care professionals to respond to family violence.

METHODS

Underpinned by indigenous Māori customs, Atawhai combines complexity theory and participatory research methodologies to be responsive to the complexity involved in family violence. We worked with 14 primary care professionals across ten whakawhitiwhiti kōrero wānanga (meetings for deliberate dialogue) to identify and develop primary care system pathways and tools for responding to family violence. This paper focuses on the development of Atawhai through wānanga and observation methods. Methods used to capture change will be reported separately.

FINDINGS

Atawhai is a relational response to family violence, focused on developing a network of trusted relationships between health and social care professionals to support safe responses to those accessing care. This study identified four key health system pathways to responsiveness and developed associated tools to support health care responsiveness to family violence. We found the quality of relationships, both among professionals and with those accessing care, coupled with critical reflection on the systems and structures that shape policy and practice are essential in generating change within primary care settings.

CONCLUSIONS

Atawhai is a unique health care response to family violence evidenced on empirical knowledge of primary care professionals. Our theoretical lens calls attention to parts of the system often obscured by current health care responses to family violence. Atawhai presents an opportunity to develop a grassroots-informed, long-term response to family violence that evolves in response to needs.

Interventions that prevent or respond to intimate partner violence against women and violence against children: a systematic review

Efforts to prevent or respond to intimate partner violence (IPV) and violence against children (VAC) are still disparate worldwide, despite increasing evidence of intersections across these forms of violence. We conducted a systematic review to explore interventions that prevent or respond to IPV and VAC by parents or caregivers, aiming to identify common intervention components and mechanisms that lead to a reduction in IPV and VAC. 30 unique interventions from 16 countries were identified, with 20 targeting both IPV and VAC. Key mechanisms for reducing IPV and VAC in primary prevention interventions included improved communication, conflict resolution, reflection on harmful gender norms, and awareness of the adverse consequences of IPV and VAC on children. Therapeutic programmes for women and children who were exposed to IPV facilitated engagement with IPV-related trauma, increased awareness of the effects of IPV, and promoted avoidance of unhealthy relationships. Evidence gaps in low-income and middle-income countries involved adolescent interventions, post-abuse interventions for women and children, and interventions addressing both prevention and response to IPV and VAC. Our findings strengthen evidence in support of efforts to address IPV and VAC through coordinated prevention and response programmes. However, response interventions for both IPV and VAC are rare and predominantly implemented in high-income countries. Although therapeutic programmes for parents, caregivers, and children in high-income countries are promising, their feasibility in low-income and middle-income countries remains uncertain. Despite this uncertainty, there is potential to improve the use of health services to address IPV and VAC together.

Assessing primary health care provider and organization readiness to address family violence in Alberta, Canada: development of a Delphi consensus readiness tool

BACKGROUND

Family violence, which includes intimate partner abuse, child abuse, and elder abuse, is a serious public health concern. Primary healthcare (PHC) offers a vital opportunity to identify and address family violence, yet barriers prevent the effective implementation of family violence interventions in PHC settings. The purpose of this study is to improve family violence identification and response in Alberta's PHC settings by exploring readiness factors.

METHODS

An integrated knowledge translation approach, combining implementation science and participatory action research, was employed to develop a readiness assessment tool for addressing family violence within PHC settings in Alberta. The research involved three phases: phase 1 involved a rapid evidence assessment, phase 2 engaged a panel of healthcare and family violence experts to explore readiness components in the Alberta context, and phase 3 utilized a 3-round Delphi consensus-building process to refine readiness indicators.

RESULTS

Phase 1 findings from a rapid evidence assessment highlighted five main models/tools for assessing readiness to implement family violence interventions in PHC settings. In phase 2, additional concepts were identified through exploration with healthcare and family violence expert panel members, resulting in a total of 16 concepts for assessing family violence readiness within the Alberta PHC context. The 3-round Delphi consensus-building process in Phase 3 involved nine panelists, who collectively agreed on the inclusion of all concepts and indicators, yielding a total of 60 items for the proposed readiness assessment tool for addressing family violence in PHC within Alberta.

CONCLUSION

The current study lays the groundwork for future family violence intervention programs, offering insights into key components that promote readiness for implementing comprehensive programs and supporting PHC organizations in effectively addressing family violence.

Asking about violence and abuse among patients experiencing homelessness: a focus group study with healthcare professionals

BACKGROUND

People experiencing homelessness are at increased risk of violence and abuse, however, there is insufficient knowledge about rates of inquiry or readiness of healthcare professionals to address violence and abuse among this population. This study aimed to explore healthcare professionals' experiences and perceptions of asking about violence and abuse among patients experiencing homelessness.

METHODS

This study used a qualitative, interpretive, and exploratory design. We performed focus group discussions with healthcare professionals (n = 22) working at an integrative healthcare unit for people experiencing homelessness. Data were analysed using reflexive thematic analysis, following Braun and Clarke's six-phase approach. Findings are reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

RESULTS

The overarching theme of the analysis is that addressing violence and abuse is at risk of "falling through the cracks". The theme is supported by three sub-themes: Hesitance to address violence and abuse, The complex dynamics of violence and abuse in homelessness, and Challenges in addressing violence and abuse amidst competing priorities and collaborative efforts. The normalisation of violence and abuse within the context of homelessness perpetuates a "cycle" where the severity and urgency of addressing violence and abuse are overlooked or minimised, hindering effective interventions. Moreover, healthcare professionals themselves may inadvertently contribute to this normalisation. The hesitance expressed by healthcare professionals in addressing the issue further reinforces the prevailing belief that violence and abuse are inherent aspects of homelessness. This normalisation within the healthcare system adds another layer of complexity to addressing these issues effectively.

CONCLUSIONS

The findings underscore the need for targeted interventions and coordinated efforts that not only address the immediate physical needs of people experiencing homelessness but also challenge and reshape the normalised perceptions surrounding violence and abuse. By prioritising awareness, education, and supportive interventions, we can begin to "break the cycle" and provide a safer environment where violence and abuse are not accepted or overlooked.

How Health Professionals Identify and Respond to Perpetrators of Domestic and Family Violence in a Hospital Setting: A Scoping Review

There is heightened awareness that a whole-of-systems approach to perpetrator responses is key to addressing domestic and family violence (DFV). This paper reports on the findings from a scoping review which mapped the international literature on how health professionals identify and respond to perpetrators of DFV within a hospital setting. A comprehensive scoping review methodology was used. The search, spanning January 2010 to January 2022, yielded 12,380 publications from four databases. Eligibility for inclusion included peer-reviewed literature with any reference to inpatient hospital health professionals identifying or responding to perpetrators of DFV. Fourteen articles were included in the final review. The review presents the literature categorized by levels of prevention, from primary, secondary, through to tertiary preventive interventions. An additional category "other practices" is added to capture practices which did not fit into existing levels. Despite glimpses into how health professionals can identify, and respond to perpetrators of DFV, the current knowledge base is sparse. The review did not identify any mandated or formal procedures for identifying and/screening or responding to perpetration of abuse in hospitals. Rather, responses to perpetrators are inconsistent and rely on the motivation, skill, and self-efficacy of health professionals rather than an embedded practice that is driven and informed by hospital policy or procedures. The literature paints a picture of missed opportunities for meaningful work with perpetrators of DFV in a hospital setting and highlights a disjuncture between policy and practice.

Experiences of physical and emotional intimate partner violence during the COVID-19 pandemic: a comparison of prepandemic and pandemic data in a longitudinal study of Australian mothers

OBJECTIVE

There is a lack of longitudinal population-based research comparing women's experiences of intimate partner violence (IPV) prior to and during the COVID-19 pandemic. Using data from the Mothers' and Young People's Study, the prevalence of physical and emotional IPV in the first year of the pandemic is compared with earlier waves of data.

DESIGN

A prospective pregnancy cohort of first-time mothers in Melbourne, Australia was followed up over the first decade of motherhood, with a quick response study conducted during the COVID-19 pandemic. 422 women completed the primary exposure measure (IPV; Composite Abuse Scale) in the 1st, 4th and 10th year postpartum and the additional pandemic survey (June 2020-April 2021).

OUTCOME MEASURES

Depressive symptoms; anxiety symptoms; IPV disclosure to a doctor, friends or family, or someone else.

RESULTS

Maternal report of emotional IPV alone was higher during the pandemic (14.4%, 95% CI 11.4% to 18.2%) than in the 10th (9.5%, 95% CI 7.0% to 12.7%), 4th (9.2%, 95% CI 6.8% to 12.4%) and 1st year after the birth of their first child (5.9%, 95% CI 4.0% to 8.6%). Conversely, physical IPV was lowest during the pandemic (3.1%, 95% CI 1.8% to 5.0%). Of women experiencing IPV during the pandemic: 29.7% were reporting IPV for the first time, 52.7% reported concurrent depressive symptoms and just 6.8% had told their doctor.

CONCLUSIONS

Findings suggest that the spike in IPV-related crime statistics following the onset of the pandemic (typically incidents of physical violence) is the tip of the iceberg for women's IPV experiences. There is a need to increase the capacity of health practitioners to recognise emotional as well as physical IPV, and IPV ought to be considered where women present with mental health problems.

Training Australian general practitioners to counsel women experiencing intimate partner abuse (WEAVE): a pre-post training analysis

BACKGROUND

Evaluations of Intimate Partner Abuse training for general practitioners is limited. The Women's Evaluation of Abuse and Violence Care study trialled in Australia was a primary care intervention that included delivering the Health Relationships training, a program that educates practitioners on how to provide supportive counselling and assistance to women afraid of an intimate partner. We report on effectiveness of the Healthy Relationships training program within a cluster-randomised controlled trial.

METHODS

General practitioners filled out a baseline survey and surveys before and after training, including quantitative and open-text questions on barriers and enablers to supporting victim-survivors. The Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS) tool, a validated measure, was included to assess practitioner knowledge, skills, confidence, and attitudes. General linear model repeated analysis of variance tested the difference between trial groups over time.

RESULTS

Fifty-two general practitioners completed the baseline demographic survey, with 65% (19 intervention, 18 comparison) completing both pre-and-post-training surveys. There were no between-group differences in baseline characteristics. Post-training, the intervention group had significantly higher average scores than the comparison on perceived preparation to address abuse (p = .000), perceived knowledge (p = .000), actual knowledge (p = .03), and greater awareness of practice-related issues (p = .000). There were no between-group differences in PREMIS opinion domain scores on workplace issues, self-efficacy and understanding of victims. Post-training, the qualitative data indicated that the intervention practitioners (n = 24) reported increased knowledge, awareness, and confidence, while time pressures and lack of referral options impeded addressing abuse.

CONCLUSION

The Healthy Relationships Training program for general practitioners increased aspects of practitioner knowledge, skills, and confidence. However, more support is needed to change opinions and support victim-survivors sustainably.

TRIAL REGISTRATION

The WEAVE trial was registered on 21/01/2008 with the Australian New Zealand Clinical Trial Registry, number ACTRN12608000032358.

Ethical challenges in global research on health system responses to violence against women: a qualitative study of policy and professional perspectives

BACKGROUND

Studying global health problems requires international multidisciplinary teams. Such multidisciplinarity and multiculturalism create challenges in adhering to a set of ethical principles across different country contexts. Our group on health system responses to violence against women (VAW) included two universities in a European high-income country (HIC) and four universities in low-and middle-income countries (LMICs). This study aimed to investigate professional and policy perspectives on the types, causes of, and solutions to ethical challenges specific to the ethics approval stage of the global research projects on health system responses to VAW.

METHODS

We used the Network of Ethical Relationships model, framework method, and READ approach to analyse qualitative semi-structured interviews (n = 18) and policy documents (n = 27). In March-July 2021, we recruited a purposive sample of researchers and members of Research Ethics Committees (RECs) from the five partner countries. Interviewees signposted policies and guidelines on research ethics, including VAW.

RESULTS

We developed three themes with eight subthemes summarising ethical challenges across three contextual factors. The global nature of the group contributed towards power and resource imbalance between HIC and LMICs and differing RECs' rules. Location of the primary studies within health services highlighted differing rules between university RECs and health authorities. There were diverse conceptualisations of VAW and vulnerability of research participants between countries and limited methodological and topic expertise in some LMIC RECs. These factors threatened the timely delivery of studies and had a negative impact on researchers and their relationships with RECs and HIC funders. Most researchers felt frustrated and demotivated by the bureaucratised, uncoordinated, and lengthy approval process. Participants suggested redistributing power and resources between HICs and LMICs, involving LMIC representatives in developing funding agendas, better coordination between RECs and health authorities and capacity strengthening on ethics in VAW research.

CONCLUSIONS

The process of ethics approval for global research on health system responses to VAW should be more coordinated across partners, with equal power distribution between HICs and LMICs, researchers and RECs. While some of these objectives can be achieved through education for RECs and researchers, the power imbalance and differing rules should be addressed at the institutional, national, and international levels. Three of the authors were also research participants, which had potential to introduce bias into the findings. However, rigorous reflexivity practices mitigated against this. This insider perspective was also a strength, as it allowed us to access and contribute to more nuanced understandings to enhance the credibility of the findings. It also helped to mitigate against unequal power dynamics.

Perceptions and educational needs of social and healthcare professionals in the prevention of domestic violence - A focus group study

OBJECTIVE

To explore and describe social and healthcare professionals' perceptions and educational needs in relation to domestic violence and its prevention.

METHODS

A qualitative research was conducted in three European countries. Two multidisciplinary focus group interviews were conducted (in each country) among professionals and higher education teachers in the field of social and health care. Total number of participants were 32 (Finland n=12, Greece n=12, Portugal n=8). The transcribed data were analyzed by thematic analysis.

RESULTS

Participants' perceptions of domestic violence and its prevention included: multidimensional phenomenon, consequences, and addressing concern. Domestic violence was seen as a multidimensional phenomenon, which has various consequences for several aspects of life. Professionals have difficulties addressing their concern due to lack of knowledge and tools. Solutions to prevent domestic violence that the participants shared were: education, intervention, and strategies. Education was seen as the key aspect for the prevention of domestic violence. Also, professionals' communication and situation management skills, as well as national and international strategies, were seen as valuable solutions. Educational needs for prevention of domestic violence were expressed based on content, methods, and practices, such as services system and legislation.

CONCLUSION

The findings of the current study highlight the social- and healthcare professionals' need for education about domestic violence. It is essential that these professionals receive appropriate training to effectively identify and address domestic violence. The current study provides useful information for the development of relevant training/education for this group of professionals.

Assessing the Nepalese health system's readiness to manage gender-based violence and deliver psychosocial counselling

Violence against women (VAW), particularly intimate partner violence (IPV) or domestic violence, is a major public health issue, garnering more attention globally post-coronavirus disease 2019 (COVID-19) lockdown. Health providers often represent the first point of contact for IPV victims. Thus, health systems and health providers must be equipped to address survivors' physical, sexual and mental health care needs. However, there is a notable lack of evidence regarding such readiness in Nepal. This study, utilizing a concurrent triangulation design, evaluated the readiness of public health facilities in Nepal's Madhesh Province in managing VAW, focusing on providers' motivation to offer psychosocial counselling to survivors. A cross-sectional study was conducted across 11 hospitals and 17 primary health care centres, where 46 health care providers were interviewed in February-April 2022. The study employed the World Health Organization's tools for policy readiness and the Physician Readiness to Manage IPV Survey for data collection. Quantitative and qualitative data were collected via face-to-face interviews and analysed using descriptive and content analysis, respectively. Only around 28% of health facilities had trained their staff in the management of VAW. Two out of 11 hospitals had a psychiatrist, and a psychosocial counsellor was available in four hospitals and two out of 17 primary health care centres. Two-thirds of all health facilities had designated rooms for physical examinations, but only a minority had separate rooms for counselling. Though a few health facilities had guidelines for violence management, the implementation of these guidelines and the referral networks were notably weak. Hospitals with one-stop crisis management centres demonstrated readiness in VAW management. Health providers acknowledged the burden of IPV or domestic violence and expressed motivation to deliver psychosocial counselling, but many had limited knowledge. This barrier can only be resolved through appropriate training and investment in violence management skills at all tiers of the health system.

Longitudinal effectiveness of a woman-led, nurse delivered health promotion intervention for women who have experienced intimate partner violence: iHEAL randomized controlled trial

BACKGROUND

Intimate partner violence (IPV) threatens the safety, health and quality of life of women worldwide. Comprehensive IPV interventions that are tailored, take a long-term view of women's needs, including health concerns, and maximize choice and control, have the potential to effectively address heath and safety concerns. Few such interventions have been tested, including in the Canadian context.

METHODS

A parallel randomized controlled trial of adult (age 19 + years), English-speaking, Canadian women with histories of IPV randomized either to iHEAL, a tailored health promotion intervention delivered by Registered Nurses over 6-7 months, or to community service information (usual care control). Primary (Quality of Life, PTSD symptoms) and secondary outcomes (Depression, Confidence in Managing Daily Life, Chronic Pain, IPV Severity) were measured at baseline and 6, 12 and 18 months post-intervention via an online survey. Generalized estimating equations were used to test for differences by study arm in intention-to-treat (full sample) and per protocol (1 + iHEAL visit) analyses focussing on short-term (immediately post-intervention) and longer-term (1 year post-intervention) effects. Selected process evaluation data were summarized using descriptive statistics.

RESULTS

Of 331 women enrolled, 175 were randomized to iHEAL (135 who engaged in 1 + visits) and 156 to control. Women who received iHEAL showed significantly greater short-term improvement in Quality of Life compared to the control group, with these effects maintained 1 year later. Changes in PTSD Symptoms also differed significantly by group, with weaker initial effects that were stronger 1 year post-intervention. Significant moderate, short- and longer-term group effects were also observed for Depression and Confidence in Managing Daily Life. IPV Severity decreased for both groups, with significant immediate effects in favour of the intervention group that grew stronger 1 year post-intervention. There were no changes in Chronic Pain.

CONCLUSION

iHEAL is an effective, acceptable and safe intervention for diverse groups of women with histories of IPV. Trial results provide a foundation for implementation and ongoing evaluation in health care settings and systems. Delayed effects noted for PTSD Symptoms and IPV Severity suggest that longer-term assessment of these outcomes may be needed in trials of IPV interventions.

TRIAL REGISTRATION

Clinicaltrials.gov ID NCT03573778 (Registered on June 29, 2018).

Antenatal healthcare providers' knowledge, attitudes and practices regarding food insecurity in pregnancy: A qualitative investigation based at a specialist antenatal hospital in Melbourne, Australia

BACKGROUND

Food insecurity exists when accessibility and availability of nutritious food is restricted, increasing the risk of adverse health outcomes. Pregnant women are especially vulnerable to food insecurity, which is concerning as optimal nutrition to support both their own health and the health and growth of their unborn child is critical. Antenatal healthcare providers (AHPs) are central to provision of pregnancy care. We aimed to assess AHPs' knowledge, attitudes and management of food insecurity.

METHODS

Semi-structured interviews were conducted face-to-face, via telephone or online via Webex with 16 AHPs at the Royal Women's Hospital located in Melbourne, Australia. Interviews were thematically analysed according to Charmaz's constructivist grounded theory approach to ascertain AHPs' knowledge, attitudes and practices regarding food insecurity during pregnancy.

RESULTS

AHPs had limited knowledge and awareness of food insecurity in pregnancy. Lack of experience in managing food insecurity and time constraints limit their capacity to support and deliver care to food-insecure women. There was a reported lack of structure and clarity surrounding referral pathways for effective management of food insecurity during pregnancy, as well as a lack of clarity regarding practitioner responsibility in managing this issue.

CONCLUSIONS

Current assessment and management of food insecurity during pregnancy in the antenatal setting is suboptimal. Professional development strategies targeted to AHPs are urgently needed to assist optimal care of women who are food insecure during pregnancy to assist with supporting best maternal and child health.

[The necessary response of health services to gender violence. Comprehensive care and provision of integrated services]

Gender violence has multiple and serious consequences for the health of victims and their families, hence the reason for the important role that the health system plays in addressing it. Health professionals have a key role in the response, which must include early detection, care, and follow-up; actions in which primary care, because of its privileged position in the system, can play a fundamental part. This article establishes the necessary characteristics for the intervention to be effective: comprehensive care, multidisciplinary approach, intersectoral coordination, and integrated service provision; all of it community-oriented, person-centered, and adapted to its context (social factors and vulnerabilities) with an intersectional approach. The woman, her sons and daughters, and other cohabitants, as well as the perpetrator, are considered the object of intervention in the response, and specific guidelines for action are provided for detection, care, and follow-up. Reorientation of interventions, with emphasis on a community approach, is also proposed.

How effective are UK-based support interventions and services targeted at adults who have experienced domestic and sexual violence and abuse at improving their safety and wellbeing? A systematic review protocol

BACKGROUND

Domestic and sexual violence and abuse (DSVA) is prevalent in the UK, with wide-ranging impacts both on individuals and society. However, to date, there has been no systematic synthesis of the evidence for the effectiveness of UK-based support interventions and services for victim-survivors of DSVA. This review will aim to systematically collate, synthesise and quality assess the evidence regarding the effectiveness of UK support interventions and services targeted at those who have experienced DSVA. The review will use findings of a preliminary scoping review, as well as input from stakeholders representing domestic and sexual violence third sector organisations to identify and prioritise the most relevant outcomes to focus on.

METHODS

We will undertake a systematic search for peer-reviewed literature in MEDLINE, EMBASE, PsycINFO, Social Policy and Practice, Applied Social Sciences Index and Abstracts (ASSIA), International Bibliography of the Social Sciences (IBSS), Sociological abstracts and SSCI. Grey literature will be identified by searching grey literature databases, circulating a call for evidence to local and national DSVA charities and organisations, and targeted website searching. Two reviewers will independently perform study selection and quality appraisal, with data extraction undertaken by one reviewer and checked for accuracy by a second reviewer. Narrative synthesis will be conducted, with meta-analysis if possible.

DISCUSSION

Existing individual studies and evaluations have reported positive impacts of support interventions and services for those who have experienced DSVA. Thus, it is expected that this review and synthesis will provide robust and conclusive evidence of these effects. It will also allow comparisons to be made between different types of support interventions and services, to inform policy makers and funders regarding the most effective ways of reducing domestic and sexual violence and abuse and its impacts.

Seeking Help From Primary Health-Care Providers in High-Income Countries: A Scoping Review of the Experiences of Migrant and Refugee Survivors of Domestic Violence

Migrant and refugee women experiencing domestic violence (DV) may face compounding factors that impact their ability and experiences of seeking help. Health-care providers are in a unique position to identify and assist victims of DV, however, they often lack the confidence and training to do this well. Little is known of the health-care experiences of migrant and refugee women experiencing abuse when they access primary health care (PHC). Using scoping review methodology, we undertook a systematic search of seven databases (Medline, Scopus, ProQuest, CINAHL, Informit Complete, and Google Scholar). We sought peer-reviewed and grey literature, published in English between January 1980 and August 2021 that identified women (18+) who had experienced DV, from low- or middle-income countries (LMICs), seeking help or health care in a primary care setting of a high-income country (HIC). Nine articles met the inclusion criteria. Findings identify sociocultural and sociopolitical barriers for migrant and refugee women seeking help for DV, which are contextualized within the ecological model. Migration-related factors and fear were major barriers for migrant and refugee women, while kindness, empathy and trust in health-care providers, and children's well-being were the strongest motivators for help-seeking and disclosure. This review provides insight into an under-researched and marginalized group of victim-survivors and highlights the need for increased awareness, guidance, and continuing education for health-care providers and health-care systems to provide best practice DV care for migrant and refugee women.

"Secrets From the Children's Room": New Understandings of Inappropriate and Abusive Sexual Behavior Among Siblings after the COVID-19 Crisis in Israel

This article discusses the COVID-19 crisis's impact on inappropriate and abusive sexual behavior among siblings (IASBAS) and how perceptions of this phenomenon affect construction of the post-crisis reality in Israel. Sibling sexual abuse, the most frequent type of sexual assault against children, does not occur in a vacuum; it is affected by the environment in which children live and develop. The pandemic created situational risk factors and a "germination substrate" for risk of abuse in "normative" families and escalation in families in which it had previously occurred. The first part of the article, based on research data and reports, reviews the objective reality that emerged in Israel and worldwide due to the pandemic. Part two describes situational risk factors converging to a new dangerous situation for children's abuse and victimization that resulted from this crisis: domestic violence (direct, indirect, and sexual), at-risk children returning and staying at home, increased exposure to online sexual content, parental dysfunction, and lack of formal and informal support sources. These risk factors are mutually reinforcing, thus exacerbating the risk of sexual assault among siblings. Part three describes the etiology characterizing the complex phenomenon of IASBAS. Part four discusses the significance of the risk factors at various stages and conditions for its development, identification, prevention or preventing escalation, and providing professional support, all of which affect the post-crisis reality. Part five offers recommendations for prevention, detection, and intervention that help deal with the reality "the day after."

Attitudes and behaviours of family physicians towards clinical practice around intimate partner violence: a view from the Çankaya district of Ankara, Turkey

BACKGROUND

Although family physicians (FPs) often encounter patients who have been subjected to intimate partner violence (IPV), the data on FPs' response to IPV is limited. This study aimed to determine FPs' attitudes towards IPV survivors in the Çankaya district of Ankara, Turkey.

METHODS

An online questionnaire designed to elicit sociodemographic information and FPs' attitudes towards IPV was distributed between 20 August 2021 and 20 October 2021.

RESULTS

Eighty-nine FPs participated in the study. Of the participants, 71.9% had a patient diagnosed with IPV during their practice. Of these physicians, 100% diagnosed physical, 56.3% sexual, 71.9% psychological, 53.1% economic, and 10.9% cyber violence. Among these physicians, sexual, psychological, and economic violence were determined at higher rates by family medicine specialists (FMSs) compared to general practitioners (GPs), by FPs who had received IPV training compared to those who were untrained, and by female physicians compared to males (P <0.05). Despite diagnosing IPV, some physicians did not intervene/guide their patients, and some only consoled their patients because they thought the situation was inevitable. The reasons for not taking official action included insufficient time, feeling uncomfortable talking about violence, lack of information about the detection and reporting, and the thought that the woman would not leave her abusive partner.

CONCLUSIONS

The results showed that among the physicians who encountered IPV, female sex, family medicine speciality training, and IPV training resulted in acting more consciously in diagnosing violence, implementing referral and notification systems, and approaching IPV survivors. The prevention of IPV could be made possible by supporting FPs with ongoing training, breaking down stereotypes and prejudices about gender roles, and changing the structures that maintain unequal power relationships.

Factors and consequences associated with intimate partner violence against women in low- and middle-income countries: A systematic review

Intimate Partner Violence (IPV) is a global public health issue, with notably high prevalence rates observed within Low-and Middle-Income Countries (LMICs). This systematic review aimed to examine the risk factors and consequences associated with IPV against women in LMICs. Following PRISMA guidelines, we conducted a systematic review using three databases: Web of Science, ProQuest Central, and Scopus, covering the period from January 2010 to January 2022. The study included only peer-reviewed journal articles in English that investigated IPV against women in LMICs. Out of 167 articles screened, 30 met the inclusion criteria, comprising both quantitative and mixed-method studies. Risk factors of IPV were categorised as: demographic risk factors (23 studies), family risk factors (9 studies), community-level factors (1 studies), and behavioural risk factors (14 studies), while consequences of IPV were categorised as mental health impacts (13 studies), physical impacts (5 studies), and societal impacts (4 studies). In this study, several risk factors were identified including lower levels of education, marriage at a young age, poor wealth indices, rural residential areas, and acceptance of gender norms that contribute to the prevalence of IPV in LMICs. It is essential to address these factors through effective preventive policies and programs. Moreover, this review highlights the necessity of large-scale, high-quality policy-driven research to further examine risk factors and consequences, ultimately guiding the development of interventions aimed at preventing IPV against women in LMICs.

"Psychological Injuries Are Not Visible": Experiences and Perceptions of Midwives and Nurses about Domestic Violence during Pregnancy

This study aimed to describe perceptions and experiences of nurses and midwives working in primary care about domestic violence (DV) in pregnancy. Data were collected by conducting in-depth face-to-face interviews with 10 midwives and 7 nurses working in seven family health centers between July 17 and August 28, 2020. Five main themes emerged: "The causes of domestic violence," "Difficulty recognizing domestic violence," "Obstacles to revealing domestic violence," "Obstacles to Assisting/Supporting domestic violence in pregnant women," and "Solutions to prevent domestic violence in pregnancy." Midwives/nurses feel inadequate and unprepared to recognize the symptoms of DV and to guide and support women and they are willing to take an active role in managing DV. It is recommended that they should be trained on DV, a monitoring system should be established including primary healthcare services and a measurement tool should be developed.

Risk factors and health consequences of experiencing reproductive coercion: a scoping review protocol

INTRODUCTION

Reproductive coercion (RC) describes behaviours that interfere with an individual's reproductive autonomy and decision-making. RC can be a form of intimate partner violence and overlaps with other forms of gender-based violence, such as sexual violence. Health settings are well placed to identify and intervene to support patients experiencing RC, however, the lack of conceptual clarity on RC means that health providers are not easily able to identify those at risk of experiencing RC. To facilitate appropriate identification and development of interventions, there is a need to understand the risk factors related to experiencing RC and associated health consequences.

AIM

To assess the current scope of evidence in relation to risk factors and health consequences of experiencing RC.

METHODS AND ANALYSIS

Eligible articles for inclusion in the scoping review will be original peer-reviewed literature that describe risk factors and health consequences of any type of RC. Studies on humans published in English since 2010 will be included. The proposed scoping review will be conducted in accordance with the JBI Methodology. This protocol is reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Five electronic databases, OVID Medline, CINAHL, Scopus, PsychINFO and Embase, will be searched for relevant literature from 1 January 2010 to 23 January 2023. Two reviewers will individually screen and review articles for eligibility, and conflicts will be resolved by a third reviewer. Data will be charted and reported using a tool developed for the purpose of this review.

ETHICS AND DISSEMINATION

Findings will be disseminated in publications and presentations to relevant stakeholders. Ethical approval is not required as data from publicly available literature sources will be used. Available evidence will be mapped across the breadth of eligible studies to identify associated risk factors and health consequences of RC.

Assessing essential service provision for prevention and management of violence against women in a remote indigenous community in Amantaní, Peru

BACKGROUND

Women living in indigenous communities in Peru currently experience extremely high rates of intimate partner violence (IPV). Over the past 10 years, there has been a large multi-sectoral initiative to establish a national network of Centros de Emergencia de la Mujer (Women's Emergency Centres) that integrate health and police services, and substantial increase in efforts from non-governmental organisations in supporting survivors of violence. However, there is currently little evidence on how existing services meet the needs of indigenous women experiencing violence in Peru.

METHODS

As part of a broader mixed-methods participatory VAWG prevention study, we assessed existing service provision for women experiencing violence in an indigenous Quechua community from Amantaní, Peru. This involved 17 key informant interviews with legal, government, police, and civil society representatives. We used the UN Women Essential Services Package for Women and Girls Subject to Violence framework to guide our analysis.

RESULTS

Participants identified major gaps in existing services for indigenous women survivors of violence in Peru. They discussed survivors and perpetrators not being identified by the health system, a lack of IPV response training for health professionals, IPV not being prioritised as a health concern, and a lack of health services that are culturally appropriate for indigenous populations. Survivors who report to police are often treated poorly and discriminated against. Legal systems were perceived as insufficient and ineffective, with inadequate legal measures for perpetrators. While legal and policy frameworks exist, they are often not applied in practice. Service provision in this region needs to adopt an intercultural, rights based, gendered approach to IPV response and prevention, considering cultural and linguistic relevance for indigenous populations.

CONCLUSION

The role of structural violence in perpetuating indigenous women's experiences of violence and undermining their access to services must be central to designing and implementing appropriate policies and services if they are to meet the needs of indigenous women in Peru.

Screening for Intimate Partner Violence Experience and Use in the Veterans Health Administration

Importance

The practice of screening women for intimate partner violence (IPV) in health care settings has been a critical part of responding to this major public health problem. Yet, IPV prevention would be enhanced with detection efforts that extend beyond screening for IPV experiences to identifying those who use violence in relationships as well.

Objective

To determine rates of IPV experiences and use (ie, among perpetrators of IPV) and factors associated with disclosures among adult patients seeking mental health services at the Veterans Health Administration.

Design, Setting, and Participants

This cross-sectional study used electronic medical record data drawn from a quality improvement initiative at 5 Veterans Health Administration medical centers conducted between November 2021 and February 2022 to examine IPV disclosures following concurrent screening for IPV experience and use. Participants included patients engaged in mental health services. Data were analyzed in April and May 2023.

Exposure

Mental health clinicians were trained to screen for IPV experience and use concurrently and instructed to screen all patients encountered through routine mental health care visits during a 3-month period.

Main Outcomes and Measures

Outcomes of interest were past-year prevalence of IPV use and experience, sociodemographic characteristics, and clinical diagnoses among screened patients.

Results

A total of 200 patients were offered IPV screening. Of 155 participants (mean [SD] age, 52.45 [15.65] years; 124 [80.0%] men) with completed screenings, 74 (47.7%) denied past-year IPV experience and use, 76 (49.0%) endorsed past-year IPV experience, and 72 (46.4%) endorsed past-year IPV use, including 67 participants (43.2%) who reported IPV experience and use concurrently; only 9 participants (5.8%) endorsed unidirectional IPV experiences and 5 participants (3.2%) endorsed unidirectional IPV use. Patients who reported past-year IPV experience and use were younger than those who denied IPV (experience: mean difference, -7.34 [95% CI, 2.51-12.17] years; use: mean difference, -7.20 [95% CI, 2.40-12.00] years). Patients with a posttraumatic stress disorder diagnosis were more likely to report IPV use (43 patients [59.7%]) than those without a posttraumatic stress disorder diagnosis (29 patients [40.3%]; odds ratio, 2.14; [95% CI, 1.12-4.06]). No other demographic characteristics or clinical diagnoses were associated with IPV use or experience.

Conclusions and Relevance

In this cross-sectional study of IPV rates and associated factors, screening for IPV found high rates of both IPV experience and use among patients receiving mental health care. These findings highlight the benefit of screening for IPV experience and use concurrently across gender and age. Additionally, the associations found between PTSD and IPV use underscore the importance of strengthening and developing additional targeted treatment for IPV.

General practice as a place to receive help for domestic abuse during the COVID-19 pandemic: a qualitative interview study in England and Wales

BACKGROUND

General practice is an important place for patients experiencing or perpetrating domestic violence and abuse (DVA), and for their children to seek and receive help. While the incidence of DVA may have increased during the COVID- 19 pandemic, there has been a reduction in DVA identifications and referrals to specialist services from general practice. Concurrently there has been the imposition of lockdown measures and a shift to remote care in general practices in the UK.

AIM

To understand the patient perspective of seeking and receiving help for DVA in general practice during the COVID-19 pandemic. This was then compared with experiences of general practice healthcare professionals.

DESIGN AND SETTING

A qualitative interview study in seven urban general practices in England and Wales, as part of a feasibility study of IRIS+, an integrated primary care DVA system-level training and support intervention.

METHOD

Semi-structured interviews with 21 patients affected by DVA and 13 general practice healthcare professionals who had received IRIS+ training. Analysis involved a Framework approach.

RESULTS

Patients recounted positive experiences of seeking help for DVA in general practice during the pandemic. However, there have been perceived problems with the availability of general practice and a strong preference for face-to-face consultations, over remote consultations, for the opportunities of non- verbal communication. There were also concerns from healthcare professionals regarding the invisibility of children affected by DVA.

CONCLUSION

Perspectives of patients and their families affected by DVA should be prioritised in general practice service planning, including during periods of transition and change.

An evidence-based primary health care intervention to address domestic violence against women in Brazil: a mixed method evaluation

BACKGROUND

Health systems have a critical role in a multi-sectoral response to domestic violence against women (DVAW). However, the evidence on interventions is skewed towards high income countries, and evidence based interventions are not easily transferred to low-and middle-income countries (LMIC) where significant social, cultural and economic differences exist. We evaluated feasibility and acceptability of implementation of an intervention (HERA-Healthcare Responding to Violence and Abuse) to improve the response to DVAW in two primary health care clinics (PHC) in Brazil.

METHODS

The study design is a mixed method process and outcome evaluation, based on training attendance records, semi-structured interviews (with 13 Primary Health Care (PHC) providers, two clinic directors and two women who disclosed domestic violence), and identification and referral data from the Brazilian Epidemiological Surveillance System (SINAN).

RESULTS

HERA was feasible and acceptable to women and PHC providers, increased providers' readiness to identify DVAW and diversified referrals outside the health system. The training enhanced the confidence and skills of PHC providers to ask directly about violence and respond to women's disclosures using a women centred, gender and human rights perspective. PHC providers felt safe and supported when dealing with DVAW because HERA emphasised clear roles and collective action within the clinical team. A number of challenges affected implementation including: differential managerial support for the Núcleo de Prevenção da Violência (Violence Prevention Nucleus-NPV) relating to the allocation of resources, monitoring progress and giving feedback; a lack of higher level institutional endorsement prioritising DVAW work; staff turnover; a lack of feedback from external support services to PHC clinics regarding DVAW cases; and inconsistent practices regarding documentation of DVAW.

CONCLUSION

Training should be accompanied by system-wide institutional change including active (as opposed to passive) management support, allocation of resources to support roles within the NPV, locally adapted protocols and guidelines, monitoring progress and feedback. Communication and coordination with external support services and documentation systems are crucial and need improvement. DVAW should be prioritised within leadership and governance structures, for example, by including DVAW work as a specific commissioning goal.

What a critical public health perspective can add to the analysis of healthcare responses to gender-based violence that focus on asking

In this comment I analyze the effects of approaching gender-based violence as a public health problem, that the health system should address through 'daring to ask'. I acknowledge the potential of the 'daring to ask' strategy, but I also argue that asking has effects, and that we should be aware of them.

Assessing the use of clinical guidelines against domestic violence in southern Sweden: A mixed-methods study

BACKGROUND AND AIM

Domestic violence is a prevalent public health issue. While clinical guidelines and care programs for its identification and handling have been formulated in all administrative regions of Sweden, their degree of implementation is largely unknown. This study aims to assess the implementation of one administrative region's care program, including how it is seen to align with and function in clinical practice, and any perceived barriers to or facilitators of its use.

METHODS

A survey was distributed to first-line managers for healthcare units with patient contact in the region (n = 807). The responses were analysed using descriptive statistics. Open responses were analysed thematically. Group interviews (n = 5) were held with caregivers (n = 15) working primarily with young patients and analysed thematically.

RESULTS

73% of the survey respondents reported previous awareness of the care program, and 27% reported knowledge of its content. The extent to which their staff knew about and followed the care program was assessed to be relatively low. The survey response rate was 19%. Among interview participants, knowledge of the care program was generally quite low. Survey responses and interview discussions pointed to the importance of developing routines, of collegial and managerial support and of training on domestic violence and the care program.

CONCLUSION

This study indicates that the knowledge and use of the regional care program is limited among healthcare staff, including among those working with young patients. This underscores the importance of information and training for furthering the implementation of clinical guidelines on domestic violence.

Midwife-led pandemic telemedicine services for maternal health and gender-based violence screening in Bangladesh: an implementation research case study

BACKGROUND

The COVID-19 pandemic disrupted maternal and newborn health services in Bangladesh, exacerbating the large gaps in service utilization that existed prior to the pandemic. As part of its response, Bangladesh initiated remote antenatal and postnatal care telemedicine services led by midwives in 36 sub-district hospitals across five of Bangladesh's 64 districts. Gender-based violence screening and referral were integrated into the service to address a reported rise in violence following the country's pandemic lockdown.

METHODS

Mixed-methods implementation research was used to develop an intrinsic case study describing the design and implementation of the telemedicine program. Qualitative analysis comprised document review, key informant interviews, and focus group discussions. Quantitative analysis employed an interrupted time series analysis with segmented multi-variate regression to compare maternity care service use trends before and after implementation. Poisson regression analysis was used to examine the trend in number of gender-based violence remote screenings, sessions held, and cases identified.

RESULTS

A statistically significant change in trend for onsite antenatal and postpartum care as well as women seeking care at the hospital as a result of postpartum hemorrhage arising in the community was observed following the introduction of telemedicine. Facility births and cases of eclampsia appropriately identified and managed also had significant increases. In addition, over 6917 women were screened for GBV, 223 received counseling and 34 referrals were made, showing a statistically significant increase in frequency over time following the implementation of the telemedicine program. Challenges included that not all midwives adopted GBV screening, some women were reluctant to discuss GBV, there was an unanticipated need to introduce a patient visit scheduling system in all intervention hospitals, and many women were not reachable by phone due to lack of access or network coverage.

CONCLUSIONS

Maternal health and gender-based violence telemedicine led by midwives was an effective, low-cost intervention in Bangladesh for addressing pandemic and pre-pandemic gaps in service use. Other low and middle-income countries planning to implement remote maternal health interventions via midwives should consider whether a patient visit scheduling system needs to be introduced, as well as limitations around mobile phone access and connectivity. Future research should include care quality oversight and improvement, and a more well-informed strategy for facilitating effective GBV screening.

Obstacles and Limitations in the Use of Protocols Responding Intimate Partner Violence Against Women from the Health System in Spain

Intimate partner violence against women (IPVAW) is a public health problem that affects women worldwide. Consequently, victims frequently go to healthcare centers, usually with a cover reason. To address this problem, national and autonomic protocols to respond to IPVAW in health systems have been developed in Spain. In this regard, the role of primary care physicians (PCPs) will be essential for addressing IPVAW, but they could encounter obstacles in doing so. The purpose of this study was to explore how IPVAW is addressed in healthcare centers in Spain. This study synthesized the information available in the protocols to address IPVAW among health care workers in Spain and analyzed it according to World Health Organization (WHO) guidelines. Additionally, PCPs' perspectives on these protocols and the nature of IPVAW attention from healthcare centers were explored through a focus group. The findings displayed that, although the protocols mostly conform to WHO guidelines, they are insufficient to address IPVAW. Generally, PCPs were unaware of the existence of the protocols and referred to the lack of training in IPVAW and protocol use as one of the main obstacles to intervening, along with a lack of time and feelings as well as cultural, educational, and political factors. The adoption of measures to ensure that PCPs apply these protocols correctly and to approach PCPs' obstacles for addressing IPVAW in consultations will be crucial for the care of victims.

Evaluation of Multidimensional Functional Impairment in Adult Sexual Assault Survivors, with a Focus on Its Psychological, Physical, and Social Dimensions, Based on Validated Measurements: A PRISMA Systematic Review

Sexual violence (SV) is widely prevalent around the world: according to studies, 18 to 51% of women and 1 to 9% of men experience it at some point in their lives. Yet, experiences of SV are rarely disclosed outside the private sphere. Pathologies, acute or chronic, can be associated with SV. The study of the links between SV and health is often fragmented, viewed through the lens of a specific pathology, yet SV certainly has an impact on the different dimensions of the functioning of survivors (physical, psychological, social, and so on), whether or not there is an identified pathology at the origin of this impact. No synthesis of the knowledge on functional impairment in adult sexual assault survivors has been identified to date. Therefore, we conducted a systematic review according to the PRISMA recommendations, focusing on the assessment via validated scales or standardized measurements of the different dimensions of functional impairment in sexual assault survivors aged 15 and over, excluding abuse in childhood and polyvictimization. We searched the Medline database from its inception to October 2022, identifying 1130 articles. Two evaluators carried out their analysis, and fifty-one articles were retained. In the end, only 13 articles were included. Their quality was assessed by referring to their compliance with STROBE recommendations. Of these 13 articles, only 4 have a quality level deemed to be satisfactory, and they relate to 4 dimensions of functioning: psychological, sexual, physical (pain), and social. The main results were that survivors reported increased restrictions of activities, sexual dysfunctions such as vulvodynia or dyspareunia, decreased social satisfaction and functioning, and decreased self-esteem and quality of life compared to the general population. To date, evidence for functional impairment is very limited, preventing researchers and clinicians from gaining clear and well-established knowledge about the functioning of sexual assault survivors. Research in this area needs to evolve urgently.

"You just want to feel safe when you go to a healthcare professional:" Intimate partner violence and patient safety

Since the early 1990s, researchers and policymakers in the United States have addressed the concept of patient safety in healthcare systems. Traditionally, scholars have conceptualized patient safety as health care that is free from medical error and harm. However, sociologists have called for a more complex understanding of patient safety that includes relational aspects of safety. Although marginalized groups face unique threats to safety, intimate partner violence (IPV) survivors have been largely overlooked within the literature on patient safety. This study addresses that gap. Using the case of IPV, I find that survivors construct healthcare spaces as ideologically safe, but their experiences do not reflect this. Survivors' narratives reveal that patient safety is complex, multi-faceted, and relational. I argue that experiences of safety, or lack thereof, are situated within larger systems of organizational power, relational power hierarchies, and systems of inequalities. These findings have implications when considering how to improve IPV survivors' safety in healthcare settings.

A tale of two cities: Heterogeneous effects of COVID-19 quarantine on domestic violence in Brazil

Domestic violence calls to helplines surged worldwide immediately after COVID-19 lockdowns, but crime reporting, assaults, or homicides did not consistently rise. Using Brazilian data from health services and helplines, we analyze the impact of COVID-19 quarantine on domestic violence calls and assaults (health reports and hospitalizations). We use a difference-in-difference model to compare the evolution of domestic violence against women in municipalities that enacted the quarantine in March 2020 versus those that never did. Then, we estimate the difference in the quarantine effect between municipalities with and without protective services for women. Domestic violence calls increased by 11.8% in the first quarter of the quarantine, while health reports reduced by 12.6% a quarter later. These effects came from municipalities with protective services for women, where female hospitalizations due to assault decreased as well. In contrast, municipalities without such services saw a decrease in domestic violence calls and an increase in health reports in the first quarter. The supply of protective services for women could be a factor that explains why COVID-19-induced quarantine effects on domestic violence varied across populations. Our results suggest that when domestic violence calls increased, protective services actions prevented domestic violence from escalating into more severe cases, such as assaults.

Panorama of Intimate Partner Violence Against Women in Brazil and its Association With Self-Perception of Health: Findings From a National Representative Survey

Intimate partner violence (IPV) is a challenge in Brazil. The country holds one of the highest rates of femicide in the world, most of which are preceded by IPV. We conducted a cross-sectional study with 34,334 women, aged 18 to 59 years, from the 2019 Brazilian National Health Survey to analyze the prevalence of IPV and its subtypes among the Brazilian adult women in the last 12 months, encompassing their health consequences and the use of health services resulting from IPV. We also used logistic regression models to estimate the association of sociodemographic characteristics and self-perceived health status with IPV. The prevalence of IPV among Brazilian adult women in the last 12 months was 7.6% (95% confidence interval [CI] [7.0, 8.2]). Women aged 18 to 39 years, not married, and with income of up to 1 minimum wage (MW), had higher odds of suffering IPV. Among those who reported health consequences due to IPV, 69% reported psychological consequences, and 13.9% sought health care, mostly in primary or secondary health care services in the Brazilian Unified Health System (41.9%). Regarding the self-perceived health variables, women who reported eating problems (odds ratio [OR]  =  1.29; [1.01, 1.65]), lack of interest/absence of pleasure (OR  =  1.41; [1.11, 1.79]), depressive feelings (OR  =  1.39; [1.03, 1.88]), feeling of failure (OR = 1.75; [1.36, 2.24]), and suicidal thoughts (OR = 1.73; [1.25, 2.41]) had greater odds of reporting IPV compared to those who did not report these same perceptions. The results show that younger, divorced or single, low-income women with eating problems and mental health disorders were more likely to suffer IPV. IPV often led to health problems, and many abused women sought support from public health services. Health professionals must be trained to identify and care for these women, thereby acting as allies in preventing and reducing IPV.

A Systematic Review of Interventions to Reduce Gender-Based Violence Among Women and Girls in Sub-Saharan Africa

Sub-Saharan Africa (SSA) is disproportionately affected by gender-based violence (GBV). We systematically reviewed English language, peer-reviewed, quantitative evaluations of interventions to reduce violence against women and girls (VAWG) in SSA that involved a comparison group and reported GBV incidence, or GBV-related attitudes, norms and symptoms as an outcome. We identified 53 studies published between January 2000 and April 2020 and classified these programmes from an empowerment perspective using the following categories: social, economic, combined social and economic and psychological empowerment interventions. Our review found social empowerment interventions effective for transforming gender attitudes and norms and reducing GBV, and psychological empowerment interventions effective for managing GBV-related symptoms. The evidence for economic empowerment interventions was equivocal. Key elements of successful interventions included participatory group learning, engaging male partners, engaging the community, longer duration and utilising existing platforms. Promising approaches for further research included gender specific programmes, psychological empowerment interventions delivered by lay workers and psychological empowerment interventions focused on GBV reduction.

Adapting domestic abuse training to remote delivery during the COVID-19 pandemic: a qualitative study of views from general practice and support services

BACKGROUND

Identifying and responding to patients affected by domestic violence and abuse (DVA) is vital in primary care. There may have been a rise in the reporting of DVA cases during the COVID-19 pandemic and associated lockdown measures. Concurrently general practice adopted remote working that extended to training and education. IRIS (Identification and Referral to Improve Safety) is an example of an evidence-based UK healthcare training support and referral programme, focusing on DVA. IRIS transitioned to remote delivery during the pandemic.

AIM

To understand the adaptations and impact of remote DVA training in IRIS-trained general practices by exploring perspectives of those delivering and receiving training.

DESIGN AND SETTING

Qualitative interviews and observation of remote training of general practice teams in England were undertaken.

METHOD

Semi-structured interviews were conducted with 21 participants (three practice managers, three reception and administrative staff, eight general practice clinicians, and seven specialist DVA staff), alongside observation of eight remote training sessions. Analysis was conducted using a framework approach.

RESULTS

Remote DVA training in UK general practice widened access to learners. However, it may have reduced learner engagement compared with face-to-face training and may challenge safeguarding of remote learners who are domestic abuse survivors. DVA training is integral to the partnership between general practice and specialist DVA services, and reduced engagement risks weakening this partnership.

CONCLUSION

The authors recommend a hybrid DVA training model for general practice, including remote information delivery alongside a structured face-to-face element. This has broader relevance for other specialist services providing training and education in primary care.

Family adversity and health characteristics associated with intimate partner violence in children and parents presenting to health care: a population-based birth cohort study in England

BACKGROUND

Little is known about the clinical characteristics of children and parents affected by intimate partner violence (IPV) presenting in health-care settings. We examined the associations between family adversities, health characteristics, and IPV in children and parents using linked electronic health records (EHRs) from primary and secondary care between 1 year before and 2 years after birth (the first 1000 days). We compared parental health problems in in children and parents with and without recorded IPV.

METHODS

We developed a population-based birth cohort of children and parents (aged 14-60 years) in England, comprising linked EHRs from mother-child pairs (with no identified father) and mother-father-child triads. We followed the cohort across general practices (Clinical Practice Research Datalink GOLD), emergency departments, outpatient visits, hospital admissions, and mortality records. Family adversities included 33 clinical indicators of parental mental health problems, parental substance misuse, adverse family environments, and high-risk child maltreatment-related presentations. Parental health problems included 12 common comorbidities, ranging from diabetes and cardiovascular diseases to chronic pain or digestive diseases. We used adjusted and weighted logistic-regression models to estimate the probability of IPV (per 100 children and parents) associated with each adversity, and period prevalences of parental health problems associated with IPV.

FINDINGS

We included 129 948 children and parents, comprising 95 290 (73·3%) mother-father-child triads and 34 658 (26·7%) mother-child pairs only between April 1, 2007, and Jan 29, 2020. An estimated 2689 (2·1%) of 129 948 children and parents (95% CI 2·0-2·3) had recorded IPV and 54 758 (41·2%; 41·5-42·2) had any family adversity between 1 year before and 2 years after birth. All family adversities were significantly associated with IPV. Most parents and children with IPV had recorded adversities (1612 [60·0%] of 2689) before their first IPV recording. The probability of IPV was 0·6 per 100 children and parents (95% CI 0·5-0·6) with no adversity, increasing to 4·4 per 100 children per parents (4·2-4·7) with one adversity, and up to 15·1 per 100 parents and children (13·6-16·5) with three of more adversities. Mothers with IPV had a significantly higher prevalence of both physical (73·4% vs 63·1%, odds ratio [OR] 1·6, 95% CI 1·4-1·8) and mental health problems (58·4% vs 22·2%, OR 4·9, 4·4-5·5) than mothers without IPV. Fathers with IPV had a higher prevalence of mental health problems (17·8% vs 7·1%, OR 2·8, 2·4-3·2) and similar prevalences of physical health problems than those without IPV (29·6% vs 32·4%, OR 0·9, 0·8-1·0).

INTERPRETATION

Two in five of the children and parents presenting to health care had recorded parental mental health problems, parental substance misuse, adverse family environments, or high-risk presentations of maltreatment in the first 1000 days. One in 22 children and parents with family adversity also had recorded IPV before age 2 years. Primary and secondary care staff should safely ask about IPV when parents or children present with family adversity or health problems associated with IPV, and respond appropriately.

FUNDING

NIHR Policy Research Programme.

Perceptions of Brazilian women at a public obstetric outpatient clinic regarding domestic violence: a qualitative study

OBJECTIVE

The aim was to explore women's perceptions of violence, its causes, manifestations, consequences and responses to prevent and confront domestic violence against women in Brazilian society.

DESIGN

We conducted a qualitative study with individual, semistructured interviews. We used thematic analysis and discussed the data considering the ecological framework.

SETTING

The study was conducted in an antenatal and postnatal care service in the Brazilian National Health System. Data collection was conducted in October 2022.

PARTICIPANTS

The sample selection was intentional and sampling was conducted according to the data saturation criterion. Twelve women who attended an antenatal and postnatal care service were interviewed. The participants reported different experiences of domestic and family violence throughout their lives.

RESULTS

Based on the analysis, four themes were identified: (1) between the public and the private spheres: violence against women and its manifestations, causes and particularities; (2) factors that increase vulnerability; (3) protection system and support network: strengths and weaknesses; and (4) alternatives for the prevention and elimination of violence.

CONCLUSIONS

The perceptions of Brazilian women during pregnancy and the postpartum period regarding domestic violence included a multifaceted view of violence. The women's discourse demonstrated the difficulties that they faced in interrupting the cycle of violence and accessing support networks.

Formal and Informal Services Used by Women Who Suffer Intimate Partner Violence in Spain

Intimate partner violence (IPV) is an important public health problem. Female victims of IPV do not always use the institutional resources available to them. We conducted a cross-sectional study using data from the Spanish 2014 Macro-Survey on Violence Against Women. The findings show that 15% of the survey participants suffered from IPV in the last year. The factors associated with a higher probability of suffering IPV are being of non-Spanish nationality, being a student, having a low-educational level, having no income, being the household head, and not having a current partner. Regarding the resources used by women subjected to IPV, almost half resorted to informal sources, such as female friends and/or their own mothers. The use of formal resources was low. Therefore, IPV continues to be a problem in Spain that seems to remain in the private domain. Consequently, it is necessary to increase the availability of and access to legal resources.

Promoting Positive Masculinities to Address Violence Against Women: A Multicountry Concept Mapping Study

Interventions engaging men that challenge unequal gender norms have been shown to be effective in reducing violence against women (VAW). However, few studies have explored how to promote anti-VAW positive masculinity in young adults. This study aims to identify key multicountry strategies, as conceived by young adults and other stakeholders, for promoting positive masculinities to improve gender equity and prevent and target VAW. This study (2019-2021) involved young adults (aged 18-24 years) and stakeholders from Ireland, Israel, Spain, and Sweden. We applied concept mapping, a participatory mixed-method approach, in phases: (1) brainstorming, using semi-structured interviews with young adults (n = 105) and stakeholders (n = 60), plus focus group discussions (n = 88), to collect ideas for promoting anti-VAW positive masculinity; (2) development of an online questionnaire for sorting (n = 201) and rating ideas emerging from brainstorming by importance (n = 406) and applicability (n = 360); (3) based on sorting and rating data, creating rating maps for importance and applicability and clusters/strategies using multidimensional scaling and hierarchical cluster analysis with groupwisdom™ software; and (4) interpretation of results with multicountry stakeholders to reach agreement. The cluster map identified seven key strategies (41 actions) for promoting anti-VAW positive masculinities ranked from highest to lowest: Formal and informal education and training; Preventive education and activities in different settings/areas; Skills and knowledge; Empathy, reflection, and understanding; Media and public efforts; Policy, legislation, and the criminal justice system; and Organizational actions and interventions. Pattern matches indicated high agreement between young people and stakeholders in ranking importance (r = 0.96), but low agreement for applicability (r = 0.60). Agreement in the total sample on prioritizing statements by importance and applicability was also low (r = 0.20); only 14 actions were prioritized as both important and applicable. Young people and stakeholders suggested seven comprehensive, multidimensional, multi-setting strategies to facilitate promoting positive masculinity to reduce VAW. Discrepancy between importance and applicability might indicate policy and implementation obstacles.

Knowledge, Implementation, and Gaps of Gender-Based Violence Management Guidelines among Health Care Workers

(1) Background: Gender-based violence (GBV) is widespread globally and has a myriad of adverse effects but is vastly under-reported. Health care workers are among the first responders in GBV. The objective of this study was to assess the knowledge of health workers with regard to GBV and related management guidelines and implementation. (2) Methods: The study employed a descriptive, sequential mix-method study, beginning with the quantitative part, followed by the qualitative component. Qualitative analysis was conducted using a content framework approach. (3) Results: More than two-thirds (71.79%) of health workers were found to be generally knowledgeable about gender-based violence; however, only 36.9% had good knowledge about gender-based violence management guidelines for gender-based violence and the mean value for all the items was less than 3 which indicates poor knowledge of the management guideline. Additionally, only 36.8% found the gender-based violence management guidelines useful and practical in clinical care for gender-based violence cases. (4) Conclusions: The finding of this study revealed that knowledge of gender-based violence management guideline was not adequate among health workers and rarely used during management of GBV cases. This calls for continuous training and specific refresher courses, including on-site practical sessions, professionals' mentorship, and supervision.

Prevention interventions for interpersonal violence occurring under the influence of alcohol: A mixed method systematic review

AIMS

To (a) explore risk indicators related to interpersonal violence occurring under the influence of alcohol and to (b) search for interventions addressed towards violence perpetrators to prevent violence occurring under the influence of alcohol.

DESIGN

Mixed method systematic review. This study has been registered in the International Prospective Register of Systematic Reviews with register number CRD42021217848.

DATA SOURCES

A systematic search was conducted on PubMed, CINAHL, PsycINFO and Scopus in October 2021.

REVIEW METHODS

Two researchers independently examined 1076 papers following the inclusion criteria. After three rounds of selection (title, abstract and full text), the quality and bias assessments were conducted independently by two reviewers. The data were analysed with inductive and deductive content analyses.

RESULTS

Of the 1076 papers retrieved, 16 papers were eligible for inclusion, addressing 13 different interventions. Interventions were divided into three types (individual-, group- and family-level) and were constructed on several background frameworks, with cognitive behavioural therapy being the most common framework. Family-level interventions seemed to yield the most effective results. Violence occurring under the influence of alcohol was mostly researched as men being the perpetrators and women being the victims of violence. Several indicators that increased the risk of violence victimization or perpetration, such as trait jealousy and disparity in education, were identified.

CONCLUSION

Interventions emerging from the systematic review were heterogenous, and the outcomes of the interventions were versatile. The disparity between interventions and outcome measures made it challenging to reliably compare the effectiveness between interventions. Using standardized outcome measure instruments and unifying research on interventions are needed to reliably assess the effectiveness of different interventions.

The Role of Structural Factors in Support-Seeking Among Women Experiencing Intimate Partner Violence (IPV) in Mwanza, Tanzania: Findings From a Qualitative Study

In this qualitative study of women participating in an intimate partner violence (IPV) prevention trial, experiences of IPV and the context that shapes support-seeking were explored through in-depth interviews and focus groups discussions. Decisions to seek support were influenced by a range of factors including fear of further abuse, shame, acceptance of IPV as normal, belief that IPV is a private matter between the couple, economic dependence on male partners, and a poorly responsive legal and justice system. Gender empowerment programs need to intervene at the social, cultural, political, and economic levels that shape justification and meanings attached to IPV and women's decisions in seeking support.

A Systematic Review of Culturally Competent Family Violence Responses to Women in Primary Care

Existing culturally competent models of care and guidelines are directing the responses of healthcare providers to culturally diverse populations. However, there is a lack of research into how or if these models and guidelines can be translated into the primary care context of family violence. This systematic review aimed to synthesise published evidence to explore the components of culturally competent primary care response for women experiencing family violence. We define family violence as any form of abuse perpetrated against a woman either by her intimate partner or the partner's family member. We included English language peer-reviewed articles and grey literature items that explored interactions between culturally diverse women experiencing family violence and their primary care clinicians. We refer women of migrant and refugee backgrounds, Indigenous women and women of ethnic minorities collectively as culturally diverse women. We searched eight electronic databases and websites of Australia-based relevant organisations. Following a critical interpretive synthesis of 28 eligible peer-reviewed articles and 16 grey literature items, we generated 11 components of culturally competent family violence related primary care. In the discussion section, we interpreted our findings using an ecological framework to develop a model of care that provides insights into how components at the primary care practice level should coordinate with components at the primary care provider level to enable efficient support to these women experiencing family violence. The review findings are applicable beyond the family violence primary care context.

Health Care Providers Views on Identifying and Responding to South Asian Women Experiencing Family Violence: A Qualitative Meta Synthesis

Family violence (FV) is a universal public health problem in South Asia with negative-health outcomes for South Asian women. Health care providers (HCPs) play a pivotal role in identifying and supporting women experiencing FV, but little is known about their experiences with South Asian women. A systematic review was conducted to explore and address health care providers' views on identification and response to South Asian women experiencing FV. Nine online databases, reference lists were searched, and a priori inclusion and exclusion criteria were applied independently by two reviewers. A meta-synthesis approach was utilized to integrate findings from qualitative studies. Eight studies involving 250 participants met the inclusion criteria. Studies were published between 2007 and 2020 within South Asian countries (Pakistan, India, and Sri Lanka) and one study from the USA and UK. The meta-synthesis identified three themes: Context of societal norms and attitudes towards women in South Asia; Influence of family honor, Privacy and shame; and Concern about health care provider's personal safety. Findings revealed that FV is often perceived as a normal routine issue and is considered a "private issue" in South Asian society. Family honor and values play a pivotal role in silencing women experiencing FV as disclosure is considered shameful and disgrace to family honor. Furthermore, health care providers avoid intervening in FV cases due to risk for their personal safety. Finally, this review provides the evidence to support a specific framework for FV interventions among south Asian women for policy makers and practitioners.

Rural Differences in Victim Vulnerability and Revictimization of Intimate Partner Violence

The aim of this study was to examine the association between the victim vulnerability factors included in the intimate partner violence (IPV) risk assessment tool used by the Swedish police (Brief Spousal Assault Form for the Evaluation of Risk [B-SAFER]) and rates of IPV revictimization among female victims living in rural towns, countryside, or remote areas. This study also aimed to examine the interaction between rurality and IPV revictimization in relation to victim vulnerability. The sample consisted of 695 cases of male-to-female perpetrated IPV, which had been reported to the Swedish police and subjected to a B-SAFER assessment. Rates of revictimization were examined in police registers. The results demonstrated that several vulnerability factors could discriminate between IPV revictimization across rurality. There was also an interaction effect between rurality and IPV revictimization in relation to the number of victim vulnerability factors present, where revictimization was more common for victims with many vulnerability factors living in more sparsely populated areas.

Victim-Centered Care Among College Women of Color: A Qualitative Study

AIMS

Women of color are disproportionally affected by intimate partner violence (IPV) and sexual assault (SA), and those on college campuses may have additional risk factors. The purpose of this study was to explore how college-affiliated women of color assign meaning to their interaction with individuals, authorities, and organizations tasked to help survivors of SA and IPV.

METHODS

Semistructured focus group interviews ( N = 87) were transcribed and analyzed using Charmaz's constructivist grounded theory methodology.

RESULTS

Three priority theoretical elements were identified: what hurts , namely, distrust, uncertain outcomes, and silencing of experiences; what helps , namely, support, autonomy, and safety; and desired outcomes , namely, academic progress, supportive social networks, and self-care.

CONCLUSION

Participants were concerned about uncertain outcomes of their interaction with organizations and authorities that are set to help victims. Results can inform forensic nurses and other professionals about the care priorities and needs of college-affiliated women of color in the context of IPV and SA.