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Pereira S, Azeredo YN, Schraiber LB, Aguiar JMD, Kalichman BD, Gralia CGV, Reis MSD, Lima NP, Bacchus LJ, Colombini M, Feder G, d'Oliveira AFPL. Evaluation of an intervention to improve Primary Health Care's response to cases of domestic violence against women - São Paulo, Brazil. CIENCIA & SAUDE COLETIVA 2024; 29:e02982024. [PMID: 39194102 DOI: 10.1590/1413-81232024299.02982024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 05/08/2024] [Indexed: 08/29/2024] Open
Abstract
The aim was to analyse and improve the Primary Health Care (PHC) response to domestic violence against women (DVAW) by developing, implementing and evaluating an intervention. A pilot study evaluating the before and after of intervention implementation, using mixed methods and carried out in three phases - formative, intervention and evaluation - between August 2017 and March 2019 in two Basic Health Units (UBS) in the city of São Paulo. In this paper, we present the details and evaluation of the intervention, carried out six to twelve months after its implementation. The intervention was developed based on the findings of the formative phase and in line with the health policy that establishes the Violence Prevention Nucleus (NPV) and consisted of stablishing a care pathway; general training for all workers and specific training for the NPV; drawing up educational material and monthly case discussions over 6 months. The evaluation showed acceptability among the workers, increased identification and repertoire for caring for cases of DVAW, strengthening internal referral and the intersectoral network. We identified obstacles to the full implementation and sustainability of the intervention.
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Affiliation(s)
- Stephanie Pereira
- Grupo de Pesquisa e Intervenção Violência e Gênero nas Práticas de Saúde, Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo. Av. Dr Arnaldo 455, Cerqueira César. 01246-903 São Paulo SP Brasil.
| | - Yuri Nishijima Azeredo
- Grupo de Pesquisa e Intervenção Violência e Gênero nas Práticas de Saúde, Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo. Av. Dr Arnaldo 455, Cerqueira César. 01246-903 São Paulo SP Brasil.
| | - Lilia Blima Schraiber
- Grupo de Pesquisa e Intervenção Violência e Gênero nas Práticas de Saúde, Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo. Av. Dr Arnaldo 455, Cerqueira César. 01246-903 São Paulo SP Brasil.
| | - Janaína Marques de Aguiar
- Grupo de Pesquisa e Intervenção Violência e Gênero nas Práticas de Saúde, Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo. Av. Dr Arnaldo 455, Cerqueira César. 01246-903 São Paulo SP Brasil.
| | - Beatriz Diniz Kalichman
- Grupo de Pesquisa e Intervenção Violência e Gênero nas Práticas de Saúde, Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo. Av. Dr Arnaldo 455, Cerqueira César. 01246-903 São Paulo SP Brasil.
| | - Cecilia Guida Vieira Gralia
- Grupo de Pesquisa e Intervenção Violência e Gênero nas Práticas de Saúde, Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo. Av. Dr Arnaldo 455, Cerqueira César. 01246-903 São Paulo SP Brasil.
| | - Marina Silva Dos Reis
- Grupo de Pesquisa e Intervenção Violência e Gênero nas Práticas de Saúde, Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo. Av. Dr Arnaldo 455, Cerqueira César. 01246-903 São Paulo SP Brasil.
| | - Nayara Portilho Lima
- Grupo de Pesquisa e Intervenção Violência e Gênero nas Práticas de Saúde, Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo. Av. Dr Arnaldo 455, Cerqueira César. 01246-903 São Paulo SP Brasil.
| | - Loraine J Bacchus
- London School of Hygiene and Tropical Medicine. London England United Kingdom
| | - Manuela Colombini
- London School of Hygiene and Tropical Medicine. London England United Kingdom
| | - Gene Feder
- University of Bristol. Bristol England United Kingdom
| | - Ana Flávia Pires Lucas d'Oliveira
- Grupo de Pesquisa e Intervenção Violência e Gênero nas Práticas de Saúde, Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo. Av. Dr Arnaldo 455, Cerqueira César. 01246-903 São Paulo SP Brasil.
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Al-Salmi S, Aly FW, Najeeb FSN, Shaikh Z, Zuaiter FAOA, Doherty S, Sefen JAN. Scoping review of healthcare professionals' views on intimate partner violence in the Middle East and North Africa. BMJ Open 2024; 14:e079866. [PMID: 39174067 DOI: 10.1136/bmjopen-2023-079866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2024] Open
Abstract
OBJECTIVES This scoping review aims to survey healthcare providers (HCPs) in the Middle East and North Africa (MENA) about their knowledge, attitudes and barriers to working with women who have experienced intimate partner violence (IPV). This review aims to map the breadth of available peer-reviewed literature that may inform future educational training programmes. DESIGN Scoping review. DATA SOURCES The scoping review included studies up to December 2023 from PUBMED, Medline, COCHRANE, Cumulative Index of Nursing and Allied Health Literature, PsycINFO and Arabic medical journals. ELIGIBILITY CRITERIA Selected articles were restricted to those carried out in the MENA region, available in full text and with no date restrictions. DATA EXTRACTION AND SYNTHESIS Data were extracted from all studies to include research location, year of publication, type of journal, methodology, design, participants, knowledge, attitudes and barriers. By charting the information into a table, the data were analysed using frequency, counts and descriptive content analysis. RESULTS Of the 1060 articles reviewed, 29 eligible studies were included in this scoping review. 27% of the articles reported HCPs' lack of knowledge about IPV protocols. The dominant attitude reported was a preference to treat the presenting health complaint and avoid discussing IPV. Finally, 30% of articles reported HCPs' lack of training as the main barrier. CONCLUSION Our paper concluded that there is a lack of research in understanding the knowledge, attitudes and barriers surrounding HCPs in the MENA region and IPV. This scoping review highlights the need for further research, informed interventions and training for HCPs in the region.
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Affiliation(s)
- Sabrina Al-Salmi
- Royal College of Surgeons in Ireland and Medical University of Bahrain, Busaiteen, Bahrain
| | - Farah W Aly
- Royal College of Surgeons in Ireland and Medical University of Bahrain, Busaiteen, Bahrain
| | - Farah S N Najeeb
- Royal College of Surgeons in Ireland and Medical University of Bahrain, Busaiteen, Bahrain
| | - Zoya Shaikh
- Royal College of Surgeons in Ireland and Medical University of Bahrain, Busaiteen, Bahrain
| | - Farah A O A Zuaiter
- Royal College of Surgeons in Ireland and Medical University of Bahrain, Busaiteen, Bahrain
| | - Sally Doherty
- Royal College of Surgeons in Ireland and Medical University of Bahrain, Busaiteen, Bahrain
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Owens J, Aboul-Enein BH, Bernstein J, Dodge E, J. Kelly P. Reducing Violence Against Women and Girls in the Arab League: A Systematic Review of Preventive Interventions. TRAUMA, VIOLENCE & ABUSE 2024; 25:2219-2233. [PMID: 37970794 PMCID: PMC11155227 DOI: 10.1177/15248380231207902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
The UN's Sustainable Development Goal #5 (Gender Equity) includes violence against women and girls (VAWG), considering it as a violation of the rights of women and girls. The variety of risk factors for VAWG in Arab countries suggests the need to identify effective interventions to guide practitioners and policy makers. A systematic review of preventive interventions across the Arab League examined the outcomes of VAWG. Authors registered the study on the prospective register of systematic reviews database. Authors conducted the search for evidence up to 2023. Database searching identified 1,502 studies and after application of the eligibility criteria, 17 studies remained for inclusion. Quality appraisal used the Mixed Methods Appraisal Tool. Evidence emerged from eight Arab countries. Interventions occurred at the primary, secondary, and tertiary levels of prevention. However, only two studies employed interventions using more than one level of prevention, which considered systems strengthening and the development of community solidarity networks. The evidence revealed a lack of clear evaluation and evidence for the effectiveness of interventions and prevention alongside reactive approaches, with no evidence as to how systems may reduce or prevent VAWG. One main issue is patriarchal dominance in Arab countries creating the lack of a collective female voice in any of the evidence. However, Arab countries can change with support. Achieving the UN's Sustainable Development Goal #5 by 2030 means interventions and programs need to include more than one prevention level, consider systems and include the collective female voice.
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Affiliation(s)
- Janine Owens
- University of Manchester, Faculty of Biology, Medicine and Health, UK
| | - Basil H. Aboul-Enein
- London School of Hygiene & Tropical Medicine, Faculty of Public Health and Policy, UK
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Grand'Maison V. Resisting invisibility in healthcare responses to gender-based violence: a content analysis. HEALTH SOCIOLOGY REVIEW : THE JOURNAL OF THE HEALTH SECTION OF THE AUSTRALIAN SOCIOLOGICAL ASSOCIATION 2024; 33:144-159. [PMID: 38803283 DOI: 10.1080/14461242.2024.2350510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 04/29/2024] [Indexed: 05/29/2024]
Abstract
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.
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Colombini M, Shrestha S, Pereira S, Kalichman B, Siriwardhana P, Silva T, Halaseh R, d’Oliveira AF, Rishal P, Bhatt PR, Shaheen A, Joudeh N, Rajapakse T, Alkaiyat A, Feder G, Moreno CG, Bacchus LJ. Comparing health systems readiness for integrating domestic violence services in Brazil, occupied Palestinian Territories, Nepal and Sri Lanka. Health Policy Plan 2024; 39:552-563. [PMID: 38758072 PMCID: PMC11145909 DOI: 10.1093/heapol/czae032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 02/29/2024] [Accepted: 04/26/2024] [Indexed: 05/18/2024] Open
Abstract
Domestic violence (DV) is a global prevalent health problem leading to adverse health consequences, yet health systems are often unprepared to address it. This article presents a comparative synthesis of the health system's pre-conditions necessary to enable integration of DV in health services in Brazil, Nepal, Sri Lanka and occupied Palestinian Territories (oPT). A cross-country, comparative analysis was conducted using a health systems readiness framework. Data collection involved multiple data sources, including qualitative interviews with various stakeholders; focus-group discussions with women; structured facility observations; and a survey with providers. Our findings highlight deficiencies in policy and practice that need to be addressed for an effective DV response. Common readiness gaps include unclear and limited guidance on DV, unsupportive leadership coupled with limited training and resources. Most providers felt unprepared, lacked guidance and felt unsupported and unprotected by managers and their health system. While in Brazil most providers felt they should respond to DV cases, many in Sri Lanka preferred not to. Such organizational and service delivery challenges, in turn, also affected how health providers responded to DV cases leaving them not confident, uncertain about their knowledge and unsure about their role. Furthermore, providers' personal beliefs and values on DV and gender norms also impacted their motivation and ability to respond, prompting some to become 'activists' while others were reluctant to intervene and prone to blame women. Our synthesis also pointed to a gap in women's use of health services for DV as they had low trust in providers. Our conceptual framework demonstrates the importance of having clear policies and highlights the need to engage leadership across every level of the system to reframe challenges and strengthen routine practices. Future research should also determine the ways in which women's understanding and needs related to DV help-seeking are addressed.
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Affiliation(s)
- Manuela Colombini
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London WC1H 9RA, United Kingdom
| | - Satya Shrestha
- Kathmandu University School of Medical Sciences, Nepal and Faculty of Health Sciences, Dhulikhel 45209, Nepal
- University of Bristol, Bristol BS81UD, United Kingdom
| | - Stephanie Pereira
- Faculty of Medicine, University of São Paulo Institute of Biomedical Sciences, Sao Paulo, Sao Paulo CEP 01246 903, Brazil
| | - Beatriz Kalichman
- Department of Preventive Medicine, Faculty of Medicine, Sao Paulo CEP 01246 903, Brazil
| | - Prabhash Siriwardhana
- Department of Social Sciences, Rajarata University of Sri Lanka, Mihintale 50300, Sri Lanka
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya 20400, Sri Lanka
| | - Tharuka Silva
- Department of Psychiatry, Faculty of Medicine, Kandy, Sri Lanka
| | - Rana Halaseh
- Occupied Palestinian Territories, An-Najah National University, Palestine
| | - Ana Flavia d’Oliveira
- Faculty of Medicine, University of São Paulo Institute of Biomedical Sciences, Sao Paulo, Sao Paulo CEP 01246 903, Brazil
| | - Poonam Rishal
- Kathmandu University School of Medical Sciences, Dhulikhel Hospital, Dhulikhel 45209, Nepal
| | - Pusp Raj Bhatt
- Kathmandu University School of Medical Sciences, Dhulikhel Hospital, Dhulikhel 45209, Nepal
| | - Amira Shaheen
- Faculty of Medicine and Health Sciences, Occupied Palestinian Territories, An-Najah National University, Nablus, Palestine
| | - Nagham Joudeh
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | | | - Abdulsalam Alkaiyat
- Faculty of Medicine and Health Sciences, Occupied Palestinian Territories, An-Najah National University, Nablus, Palestine
| | - Gene Feder
- University of Bristol, Centre for Academic Primary Care, Bristol BS81UD, United Kingdom
| | - Claudia Garcia Moreno
- Formerly at Department of Reproductive Health and Research, World Health Organisation, Geneva 1211, Switzerland
| | - Loraine J Bacchus
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London WC1H 9RA, United Kingdom
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Deuba K, Shrestha R, Koju R, Jha VK, Lamichhane A, Mehra D, Ekström AM. Assessing the Nepalese health system's readiness to manage gender-based violence and deliver psychosocial counselling. Health Policy Plan 2024; 39:198-212. [PMID: 38300229 PMCID: PMC10883662 DOI: 10.1093/heapol/czae003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 12/26/2023] [Accepted: 01/29/2024] [Indexed: 02/02/2024] Open
Abstract
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.
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Affiliation(s)
- Keshab Deuba
- Department of Global Public Health, Karolinska Institutet, Stockholm, Widerströmska Huset Tomtebodavägen 18 A, Plan 3, Solna 17165, Sweden
- Public Health and Environment Research Centre (PERC), Sanepa-2, GPO Box 8975, EPC 450, Lalitpur, Bagmati, Nepal
- Knowledge to Action (K2A), Sanepa-2, Lalitpur, Bagmati 4700, Nepal
| | - Rachana Shrestha
- Department of Global Public Health, Karolinska Institutet, Stockholm, Widerströmska Huset Tomtebodavägen 18 A, Plan 3, Solna 17165, Sweden
- Public Health and Environment Research Centre (PERC), Sanepa-2, GPO Box 8975, EPC 450, Lalitpur, Bagmati, Nepal
- Knowledge to Action (K2A), Sanepa-2, Lalitpur, Bagmati 4700, Nepal
| | - Reena Koju
- Public Health and Environment Research Centre (PERC), Sanepa-2, GPO Box 8975, EPC 450, Lalitpur, Bagmati, Nepal
- Knowledge to Action (K2A), Sanepa-2, Lalitpur, Bagmati 4700, Nepal
| | - Vijay Kumar Jha
- Health Directorate, Ministry of Social Development, Sapahi, Dhanusha, Janakpur, Madhesh Province 45600, Nepal
| | - Achyut Lamichhane
- Public Health and Environment Research Centre (PERC), Sanepa-2, GPO Box 8975, EPC 450, Lalitpur, Bagmati, Nepal
- Knowledge to Action (K2A), Sanepa-2, Lalitpur, Bagmati 4700, Nepal
| | - Devika Mehra
- MAMTA Health Institute for Mother and Child, New Delhi 110048, India
- Division of Social Medicine and Global Health, Department of Clinical Sciences, Lund University, Malmö, Box 117, Lund 221 00, Sweden
| | - Anna Mia Ekström
- Department of Global Public Health, Karolinska Institutet, Stockholm, Widerströmska Huset Tomtebodavägen 18 A, Plan 3, Solna 17165, Sweden
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Bacchus LJ, d'Oliveira AFPL, Pereira S, Schraiber LB, Aguiar JMD, Graglia CGV, Bonin RG, Feder G, Colombini M. An evidence-based primary health care intervention to address domestic violence against women in Brazil: a mixed method evaluation. BMC PRIMARY CARE 2023; 24:198. [PMID: 37749549 PMCID: PMC10519067 DOI: 10.1186/s12875-023-02150-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 09/01/2023] [Indexed: 09/27/2023]
Abstract
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.
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Affiliation(s)
- Loraine J Bacchus
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Faculty of Public Health & Policy, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Ana Flávia Pires Lucas d'Oliveira
- Preventive Medicine Department, Faculty of Medicine, University of São Paulo, Av. Dr. Arnaldo, 455 Cerqueira César, 01246 903, São Paulo, Brasil.
| | - Stephanie Pereira
- Preventive Medicine Department, Faculty of Medicine, University of São Paulo, Av. Dr. Arnaldo, 455 Cerqueira César, 01246 903, São Paulo, Brasil
| | - Lilia Blima Schraiber
- Preventive Medicine Department, Faculty of Medicine, University of São Paulo, Av. Dr. Arnaldo, 455 Cerqueira César, 01246 903, São Paulo, Brasil
| | - Janaina Marques de Aguiar
- Preventive Medicine Department, Faculty of Medicine, University of São Paulo, Av. Dr. Arnaldo, 455 Cerqueira César, 01246 903, São Paulo, Brasil
| | - Cecilia Guida Vieira Graglia
- Preventive Medicine Department, Faculty of Medicine, University of São Paulo, Av. Dr. Arnaldo, 455 Cerqueira César, 01246 903, São Paulo, Brasil
| | - Renata Granusso Bonin
- Preventive Medicine Department, Faculty of Medicine, University of São Paulo, Av. Dr. Arnaldo, 455 Cerqueira César, 01246 903, São Paulo, Brasil
| | - Gene Feder
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Manuela Colombini
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Faculty of Public Health & Policy, 15-17 Tavistock Place, London, WC1H 9SH, UK
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Arora S, Bhate-Deosthali P, Rege S, Amin A, Meyer SR. Healthcare Providers' Perceptions and Experiences of Training to Respond to Violence against Women: Results from a Qualitative Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3606. [PMID: 36834300 PMCID: PMC9966429 DOI: 10.3390/ijerph20043606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/11/2023] [Accepted: 02/13/2023] [Indexed: 06/18/2023]
Abstract
Healthcare providers (HCPs) can support women affected by violence, providing a safe way for women to disclose experiences of violence and mitigating violence against women (VAW) through the identification of cases in routine clinical practice. We conducted in-depth interviews and focus group discussions with HCPs in three tertiary facilities in Maharashtra, India, who had participated in training using the World Health Organization curriculum, adapted for the Indian context. n = 21 HCPs participated in in-depth interviews and n = 10 nurses participated in two focus group discussions. The respondents indicated that the training approach and content were acceptable and that the skills learned during the training were feasible to implement. A shift in perspective from viewing VAW as a private issue to understanding it as a health issue facilitated HCPs' response. The training enabled HCPs to recognize barriers faced by women in disclosing violence and their role in supporting disclosure. HCPs reported barriers to providing care for survivors of violence, including a lack of human resources, the time during regular clinical practice, and a lack of strong referral networks. These data can be utilized to inform other efforts to train HCPs in facilities in this setting and provide evidence for ways to improve health systems' responses to VAW in low-and middle-income country settings.
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Affiliation(s)
- Sanjida Arora
- CEHAT—Center for Enquiry into Health and Allied Themes, Mumbai 400055, India
| | | | - Sangeeta Rege
- CEHAT—Center for Enquiry into Health and Allied Themes, Mumbai 400055, India
| | - Avni Amin
- Department of Sexual and Reproductive Health and Research, World Health Organization, 1211 Geneva, Switzerland
| | - Sarah R. Meyer
- Department of Sexual and Reproductive Health and Research, World Health Organization, 1211 Geneva, Switzerland
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig-Maximilians-Universität München, 81377 Munich, Germany
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Mwanza J, Kawonga M, Kumwenda A, Gray GE, Mutale W, Doherty T. Health system response to preventing mother-to-child transmission of HIV policy changes in Zambia: a health system dynamics analysis of primary health care facilities. Glob Health Action 2022; 15:2126269. [PMID: 36239946 PMCID: PMC9578454 DOI: 10.1080/16549716.2022.2126269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Zambia is focusing on attaining HIV epidemic control by 2021, including eliminating Mother to Child Transmission (eMTCT) of HIV. However, there is little evidence to understand frontline healthcare workers’ experience with the policy changes and the readiness of different health system elements to contribute to this goal. Objective To understand frontline healthcare workers’ experience of preventing mother-to-child transmission (PMTCT) of human immunodeficiency (HIV) policy changes and to explore the health system readiness to respond to rapid changes in PMTCT policy by using the health system dynamic framework. Method We conducted a qualitative study in which 35 frontline healthcare workers were selected and interviewed using a snowball sampling technique. All transcripts were analysed through thematic content analysis and deductive coding. Themes were derived and presented according to the health system dynamics framework. Results Among the ten elements of the health system dynamics framework, service delivery, context, and resources (i.e. infrastructure and supplies, knowledge and information, human resource, and finance) were critical in implementing the continuously evolving PMTCT policies. Furthermore, due to the fragmented primary health care platform in Zambia, non-governmental organisations (NGOs) were instrumental in ensuring that the PMTCT programme met the demand and requirements of the general population. Frontline healthcare workers who participated in the study described inequity in access to ART services due to the service delivery model employed in the selected study sites. Conclusion The study highlights challenges when policies are implemented without consideration for the readiness, context, and capacity in which the policy is implemented. We offer lessons that can inform implementation of universal health coverage of antiretroviral therapy (ART), a strategy many countries have adopted, despite weak health systems.
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Affiliation(s)
- Jonathan Mwanza
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Mary Kawonga
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.,Department of Community Health, Charlotte Maxeke Johannesburg Academic Hospital Johannesburg, Johannesburg, South Africa
| | - Andrew Kumwenda
- Department of Obstetrics and Gynaecology, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Glenda E Gray
- Office of the President, South Africa Medical Research Council, Cape Town, South Africa
| | - Wilbroad Mutale
- School of Public Health, University of Zambia, Lusaka, Zambia
| | - Tanya Doherty
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.,Health Systems Research Unit, South Africa Medical Research Council, Cape Town, South Africa
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Colombini M, Mayhew SH, García-Moreno C, d'Oliveira AF, Feder G, Bacchus LJ. Improving health system readiness to address violence against women and girls: a conceptual framework. BMC Health Serv Res 2022; 22:1429. [PMID: 36443825 PMCID: PMC9703415 DOI: 10.1186/s12913-022-08826-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 11/10/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND There is an increasing focus on readiness of health systems to respond to survivors of violence against women (VAW), a global human rights violation damaging women's health. Health system readiness focuses on how prepared healthcare systems and institutions, including providers and potential users, are to adopt changes brought about by the integration of VAW care into services. In VAW research, such assessment is often limited to individual provider readiness or facility-level factors that need to be strengthened, with less attention to health system dimensions. The paper presents a framework for health system readiness assessment to improve quality of care for intimate partner violence (IPV), which was tested in Brazil and Palestinian territories (oPT). METHODS Data synthesis of primary data from 43 qualitative interviews with healthcare providers and health managers in Brazil and oPT to explore readiness in health systems. RESULTS The application of the framework showed that it had significant added value in capturing system capabilities - beyond the availability of material and technical capacity - to encompass stakeholder values, confidence, motivation and connection with clients and communities. Our analysis highlighted two missing elements within the initial framework: client and community engagement and gender equality issues. Subsequently, the framework was finalised and organised around three levels of analysis: macro, meso and micro. The micro level highlighted the need to also consider how the system can sustainably involve and interact with clients (women) and communities to ensure and promote readiness for integrating (and participating in) change. Addressing cultural and gender norms around IPV and enhancing support and commitment from health managers was also shown to be necessary for a health system environment that enables the integration of IPV care. CONCLUSION The proposed framework helps identify a) system capabilities and pre-conditions for system readiness; b) system changes required for delivering quality care for IPV; and c) connections between and across system levels and capabilities.
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Affiliation(s)
| | | | - Claudia García-Moreno
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | - Gene Feder
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
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Bhatia A, Turner E, Akim A, Mirembe A, Nakuti J, Parkes J, Datzberger S, Nagawa R, Kung'u M, Babu H, Kabuti R, Kimani J, Beattie TS, d'Oliveira AF, Rishal P, Nyakuwa R, Bell S, Bukuluki P, Cislaghi B, Tanton C, Conolly A, Mercer CH, Seeley J, Bacchus LJ, Devries K. Remote methods for research on violence against women and children: lessons and challenges from research during the COVID-19 pandemic. BMJ Glob Health 2022; 7:e008460. [PMID: 36396176 PMCID: PMC9676415 DOI: 10.1136/bmjgh-2022-008460] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 08/07/2022] [Indexed: 11/19/2022] Open
Abstract
Collecting data to understand violence against women and children during and after the COVID-19 pandemic is essential to inform violence prevention and response efforts. Although researchers across fields have pivoted to remote rather than in-person data collection, remote research on violence against women, children and young people poses particular challenges. As a group of violence researchers, we reflect on our experiences across eight studies in six countries that we redesigned to include remote data collection methods. We found the following areas were crucial in fulfilling our commitments to participants, researchers, violence prevention and research ethics: (1) designing remote data collection in the context of strong research partnerships; (2) adapting data collection approaches; (3) developing additional safeguarding processes in the context of remote data collection during the pandemic; and (4) providing remote support for researchers. We discuss lessons learnt in each of these areas and across the research design and implementation process, and summarise key considerations for other researchers considering remote data collection on violence.
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Affiliation(s)
- Amiya Bhatia
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Ellen Turner
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | - Jenny Parkes
- Institute of Education, University College London, London, UK
| | | | - Rehema Nagawa
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Mary Kung'u
- Partners for Health and Development in Africa, Nairobi, Kenya
| | - Hellen Babu
- Partners for Health and Development in Africa, Nairobi, Kenya
| | - Rhoda Kabuti
- Partners for Health and Development in Africa, Nairobi, Kenya
| | - Joshua Kimani
- Partners for Health and Development in Africa, Nairobi, Kenya
| | - Tara S Beattie
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Ana Flavia d'Oliveira
- Preventive Medicine Department, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Poonam Rishal
- Department of Nursing and Midwifery, Kathmandu University School of Medical Sciences, Kavre, Nepal
| | | | - Sadie Bell
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Paul Bukuluki
- Department of Social Work and Social Administration, School of Social Sciences, Makerere University, Kampala, Uganda
| | - Beniamino Cislaghi
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Clare Tanton
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Anne Conolly
- NatCen Social Research, London, UK
- Institute for Global Health, University College London, London, UK
| | | | - Janet Seeley
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Loraine J Bacchus
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Karen Devries
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
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12
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Sapkota BP, Baral KP, Berger U, Parhofer KG, Rehfuess EA. Health sector readiness for the prevention and control of non-communicable diseases: A multi-method qualitative assessment in Nepal. PLoS One 2022; 17:e0272361. [PMID: 36178897 PMCID: PMC9524672 DOI: 10.1371/journal.pone.0272361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 07/19/2022] [Indexed: 11/25/2022] Open
Abstract
In Nepal, deaths attributable to NCDs have increased in recent years. Although NCDs constitute a major public health problem, how best to address this has not received much attention. The objective of this study was to assess the readiness of the Nepalese health sector for the prevention and control of NCDs and their risk factors. The study followed a multi-method qualitative approach, using a review of policy documents, focus group discussions (FGDs), and in-depth interviews (IDIs) conducted between August and December 2020. The policy review was performed across four policy categories. FGDs were undertaken with different cadres of health workers and IDIs with policy makers, program managers and service providers. We performed content analysis using the WHO health system building blocks framework as the main categories. Policy documents were concerned with the growing NCD burden, but neglect the control of risk factors. FGDs and IDIs reveal significant perceived weaknesses in each of the six building blocks. According to study participants, existing services were focused on curative rather than preventive interventions. Poor retention of all health workers in rural locations, and of skilled health workers in urban locations led to the health workers across all levels being overburdened. Inadequate quantity and quality of health commodities for NCDs emerged as an important logistics issue. Monitoring and reporting for NCDs and their risk factors was found to be largely absent. Program decisions regarding NCDs did not use the available evidence. The limited budget dedicated to NCDs is being allocated to curative services. The engagement of non-health sectors with the prevention and control of NCDs remained largely neglected. There is a need to redirect health sector priorities towards NCD risk factors, notably to promote healthy diets and physical activity and to limit tobacco and alcohol consumption, at policy as well as community levels.
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Affiliation(s)
- Bhim Prasad Sapkota
- CIH Center for International Health, LMU Munich, Munich, Germany
- Teaching & Training Unit, Division of Infectious Diseases and Tropical Medicine, University Hospital, LMU Munich, Munich, Germany
- * E-mail: ,
| | | | - Ursula Berger
- Institute of Medical Information Processing Biometry and Epidemiology, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | - Klaus G. Parhofer
- Medical Department-4, University Hospital, LMU Munich, Munich, Germany
| | - Eva A. Rehfuess
- Institute of Medical Information Processing Biometry and Epidemiology, LMU Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
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Almegewly WH, Hawamdah S, Moussa FL, Dator WLT, Alonezi A, Al-Eissa M. Measuring Nurses' and Physicians' Attitudes and Perceptions of the Appropriate Interventions towards Intimate Partner Violence in Saudi Arabia. Healthcare (Basel) 2022; 10:1430. [PMID: 36011088 PMCID: PMC9408212 DOI: 10.3390/healthcare10081430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 07/26/2022] [Accepted: 07/26/2022] [Indexed: 12/02/2022] Open
Abstract
Background: Intimate partner violence (IPV) is considered the most common form of violence against women worldwide, concerning public health, safety, and human rights. However, little to no studies in Saudi Arabia have explored the attitude and perception of health care providers working in emergency departments toward IPV. This study aimed to measure the attitude and perception of Emergency Room (ER) health care providers towards the appropriate intervention for IPV. Methods: This is a cross-sectional quantitative study. Data was collected from a convenient sample of nurses (n = 88) and physicians (n = 18) working in ER, using Readiness to Manage Intimate Partner Violence Survey (PREMIS). Data was collected from two hospitals in Riyadh, Saudi Arabia, and descriptive analysis was used to analyze the data. Results: The majority of the respondents were aged 18−40 (n = 106, 78%), while 22% were 41−60 years old, 69% were female, and 31% were male. Eighty-five percent were nurses and 15% were physicians. The majority of the respondents did not have any training on IPV and had gained knowledge or skills mostly during their medical/nursing classroom and clinical training. The analysis revealed that the participants had moderate levels of overall preparedness, knowledge about IPV, and perceived knowledge, with a mean score of 2.30, 18.62, and 2.18, respectively. The respondents had low scores in practice issues in new diagnosis (0.91), current screening (1.69), and actions when IPV is identified (0.91). The perceived preparedness and knowledge have a significant positive correlation, as shown by an r value of 0.8476 and a p-value of <0.05. Conclusion: The study shows that participants stated minimal previous IPV knowledge and training. It is necessary to put in place adequate resources and specific training programs to overcome this issue for both ER nurses and physicians.
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Affiliation(s)
- Wafa Hamad Almegewly
- Department of Community Health Nursing, College of Nursing, Princess Nourah bint Abdulrahman University, Riyadh 11671, Saudi Arabia;
| | | | - Fatchima Laouali Moussa
- Department of Medical-Surgical Nursing, College of Nursing, Princess Nourah bint Abdulrahman University, Riyadh 11671, Saudi Arabia; (F.L.M.); (W.L.T.D.)
| | - Wireen Leila Tanggawohn Dator
- Department of Medical-Surgical Nursing, College of Nursing, Princess Nourah bint Abdulrahman University, Riyadh 11671, Saudi Arabia; (F.L.M.); (W.L.T.D.)
| | - Anwar Alonezi
- Department of Community Health Nursing, College of Nursing, Princess Nourah bint Abdulrahman University, Riyadh 11671, Saudi Arabia;
| | - Majid Al-Eissa
- Department of National Family Safety Program, Ministry of National Guard Health Affairs (MNGHA), King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh 11426, Saudi Arabia;
- Department of Pediatrics, King Abdullah International Medical Research Center (KAIMRC), Riyadh 11481, Saudi Arabia
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Kimber M, Vanstone M, Dimitropoulos G, Collin-Vézina D, Stewart D. Researching the Impact of Service provider Education (RISE) Project - a multiphase mixed methods protocol to evaluate implementation acceptability and feasibility. Pilot Feasibility Stud 2022; 8:135. [PMID: 35780156 PMCID: PMC9250197 DOI: 10.1186/s40814-022-01096-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/20/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Health and social service providers receive limited education on recognizing and responding to family violence. With adequate education, providers could be prepared to identify individuals subjected to family violence and help reduce the risk of associated impairment. Informed by the Active Implementation Frameworks, our research will determine the scope of strategies needed for the uptake and sustainability of educational interventions focused on family violence for providers. It will also determine the acceptability, feasibility, and proof-of-concept for a new educational intervention, called VEGA (Violence, Evidence, Guidance, Action), for developing and improving primary care provider knowledge and skills in family violence. METHODS This paper details the protocol for the Researching the Impact of Service provider Education (RISE) Project. The RISE Project follows a sequential multiphase mixed method research design; qualitative and quantitative data are being collected and integrated over three conceptually and methodologically linked research phases. Activities primarily occur in Ontario, Alberta, and Quebec. Phase 1 uses a sequential exploratory mixed method research design to characterize the scope and salience of learning and implementation needs and preferences for family violence education. Phase 2 will use an embedded mixed method research design to determine whether VEGA technology supports providers to achieve their family violence learning goals with effectiveness, efficiency, and satisfaction. Phase 3 will use a concurrent mixed method research design to determine acceptability, feasibility, and proof-of-concept for evaluating whether VEGA improves primary care providers' knowledge and skills in family violence. This final phase will provide information on implementation strategies for family violence education in the "real world." It will also generate data on provider recruitment, retention, and data completeness, as well as exploratory estimates of the effect for provider outcome measures proposed for a randomized controlled trial. DISCUSSION The RISE Project comprehensively integrates an implementation approach to improve family violence education for the health and social service professions. It will provide important information about factors that could influence the uptake and effectiveness of a health profession's educational intervention into the real world, as well as provide foundational evidence concerning the tenability of using a randomized controlled trial to evaluate the impact of VEGA in primary care settings.
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Affiliation(s)
- Melissa Kimber
- Offord Centre for Child Studies, Department of Psychiatry and Behavioural Neuroscience, McMaster University, BAHT 132, 1280 Main Street West, Hamilton, Ontario, L8S 4K1, Canada. .,Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St West, Hamilton, ON, Canada.
| | - Meredith Vanstone
- Department of Family Medicine, McMaster University, 1280 Main St West, Hamilton, ON, Canada
| | - Gina Dimitropoulos
- Faculty of Social Work, University of Calgary, MacKimmie Tower 413, 2500 University Dr NW, Calgary, AB, Canada
| | - Delphine Collin-Vézina
- School of Social Work, McGill University, 3506 Rue University #300, Montréal, QC, Canada.,Department of Pediatrics, McGill University, 1001 Decarie Blvd, Montréal, QC, Canada
| | - Donna Stewart
- Centre for Mental Health, University of Toronto and University Health Network, EN-7-229, 200 Elizabeth Street, Toronto, ON, Canada
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15
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d’Oliveira AFPL, Pereira S, Bacchus LJ, Feder G, Schraiber LB, de Aguiar JM, Bonin RG, Vieira Graglia CG, Colombini M. Are We Asking Too Much of the Health Sector? Exploring the Readiness of Brazilian Primary Healthcare to Respond to Domestic Violence Against Women. Int J Health Policy Manag 2022; 11:961-972. [PMID: 33327691 PMCID: PMC9808197 DOI: 10.34172/ijhpm.2020.237] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 11/15/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND There is growing recognition of the health sector's potential role in addressing domestic violence (DV) against women. Although Brazil has a comprehensive policy framework on violence against women (VAW), implementation has been slow and incomplete in primary healthcare (PHC), and little is known about the implementation challenges. This paper aims to assess the readiness of two PHC clinics in urban Brazil to integrate an intervention to strengthen their DV response. METHODS We conducted 20 semi-structured interviews with health managers and health providers; a document analysis of VAW and DV policies from São Paulo and Brazil; and 2 structured facility observations. Data were analysed using thematic analysis. RESULTS Findings from our readiness assessment revealed gaps in both current policy and practice needing to be addressed, particularly with regards to governance and leadership, health service organisation and health workforce. DV received less political recognition, being perceived as a lower priority compared to other health issues. Lack of clear guidance from the central and municipal levels emerged as a crucial factor that weakened DV policy implementation both by providers and managers. Furthermore, responses to DV lost visibility, as they were diluted within generic violence responses. The organizational structure of the PHC system in São Paulo, which prioritised the number of consultations and household visits as the main performance indicators, was an additional difficulty in legitimising healthcare providers' time to address DV. Individual-level challenges reported by providers included lack of time and knowledge of how to respond, as well as fears of dealing with DV. CONCLUSION Assessing readiness is critical because it helps to evaluate what services and infrastructure are already in place, also identifying obstacles that may hinder adaptation and integration of an intervention to strengthen the response to DV before implementation.
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Affiliation(s)
| | - Stephanie Pereira
- Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | - Gene Feder
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Lilia Blima Schraiber
- Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Janaina Marques de Aguiar
- Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Renata Granusso Bonin
- Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Lewis NV, Munas M, Colombini M, d'Oliveira AF, Pereira S, Shrestha S, Rajapakse T, Shaheen A, Rishal P, Alkaiyat A, Richards A, Garcia-Moreno CM, Feder GS, Bacchus LJ. Interventions in sexual and reproductive health services addressing violence against women in low-income and middle-income countries: a mixed-methods systematic review. BMJ Open 2022; 12:e051924. [PMID: 35193906 PMCID: PMC8867339 DOI: 10.1136/bmjopen-2021-051924] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 01/17/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To synthesise evidence on the effectiveness, cost-effectiveness and barriers to responding to violence against women (VAW) in sexual and reproductive health (SRH) services in low/middle-income countries (LMICs). DESIGN Mixed-methods systematic review. DATA SOURCES Medline, Embase, Psycinfo, Cochrane, Cinahl, IMEMR, Web of Science, Popline, Lilacs, WHO RHL, ClinicalTrials.gov, Google, Google Scholar, websites of key organisations through December 2019. ELIGIBILITY CRITERIA Studies of any design that evaluated VAW interventions in SRH services in LMICs. DATA EXTRACTION AND SYNTHESIS Concurrent narrative quantitative and thematic qualitative syntheses, integration through line of argument and mapping onto a logic model. Two reviewers extracted data and appraised quality. RESULTS 26 studies of varied interventions using heterogeneous outcomes. Of ten interventions that strengthened health systems capacity to respond to VAW during routine SRH consultation, three reported no harm and reduction in some types of violence. Of nine interventions that strengthened health systems and communities' capacity to respond to VAW, three reported conflicting effects on re-exposure to some types of VAW and mixed effect on SRH. The interventions increased identification of VAW but had no effect on the provision (75%-100%) and uptake (0.6%-53%) of referrals to VAW services. Of seven psychosocial interventions in addition to SRH consultation that strengthened women's readiness to address VAW, four reduced re-exposure to some types of VAW and improved health. Factors that disrupted the pathway to better outcomes included accepting attitudes towards VAW, fear of consequences and limited readiness of the society, health systems and individuals. No study evaluated cost-effectiveness. CONCLUSIONS Some VAW interventions in SRH services reduced re-exposure to some types of VAW and improved some health outcomes in single studies. Future interventions should strengthen capacity to address VAW across health systems, communities and individual women. First-line support should be better tailored to women's needs and expectations. PROSPERO REGISTRATION NUMBER CRD42019137167.
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Affiliation(s)
- Natalia V Lewis
- Bristol Medical School (PHS), University of Bristol Faculty of Health Sciences, Bristol, UK
| | - Muzrif Munas
- Bristol Medical School (PHS), University of Bristol Faculty of Health Sciences, Bristol, UK
- Department of Psychiatry, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Manuela Colombini
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - A F d'Oliveira
- Faculty of Medicine, University of São Paulo Institute of Biomedical Sciences, Sao Paulo, Brazil
| | - Stephanie Pereira
- Faculty of Medicine, University of São Paulo Institute of Biomedical Sciences, Sao Paulo, Brazil
| | - Satya Shrestha
- Bristol Medical School (PHS), University of Bristol Faculty of Health Sciences, Bristol, UK
- School of Medical Sciences, Kathmandu University, Kathmandu, Nepal
| | - Thilini Rajapakse
- Department of Psychiatry, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Amira Shaheen
- Faculty of Medicine and Health Sciences, An-najah National University, Nablus, State of Palestine
| | - Poonam Rishal
- School of Medical Sciences, Kathmandu University, Kathmandu, Nepal
| | - Abdulsalam Alkaiyat
- Faculty of Medicine and Health Sciences, An-najah National University, Nablus, State of Palestine
| | - Alison Richards
- Bristol Medical School (PHS), University of Bristol Faculty of Health Sciences, Bristol, UK
- NIHR ARC West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Claudia M Garcia-Moreno
- Department of Reproductive Health and Research, Organisation mondiale de la Sante, Geneve, Switzerland
| | - Gene S Feder
- Bristol Medical School (PHS), University of Bristol Faculty of Health Sciences, Bristol, UK
| | - Loraine J Bacchus
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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Gaddappa S, Deshpande S, Gaikwad N, Rokade J, Prabhu P, Arora S, Rege S. Strengthening Health Systems' Response to Violence Against Women in Three Tertiary Health Facilities of Maharashtra. J Obstet Gynaecol India 2021; 71:90-95. [PMID: 34924720 DOI: 10.1007/s13224-021-01596-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 11/03/2021] [Indexed: 11/25/2022] Open
Abstract
Background Domestic violence is known to have a significant impact on the health of women. Despite this, the health system in India is not equipped to respond to women facing violence. This can be attributed to limited information on how the evidence-based guidelines can be implemented in resource-constrained settings. To fill this gap, implementation research was carried out in three tertiary medical teaching hospitals in Maharashtra. Methods The project was implemented in the OBGY, Medicine and Emergency department of a medical college and a district hospital in the state of Maharashtra. The intervention included consultation with key providers of three departments and a 5 day training of trainers on VAW. The trainers conducted 2 day onsite training for the health care providers. System-level interventions included the development of SOPs, IEC material, documentation format and identifying places for a private consultation. The research involved a pre- and post-test to assess change in KAP of providers after training, analysis of documentation register and interviews with trained providers and survivors. Results Findings indicate a significant change in knowledge, attitude and practice of the providers. Documentation registers introduced in the facility departments showed 531 women facing violence were responded by providers in 9 months. In 59% of cases, the provider suspected violence based on presenting health complaints, indicating the success of the capacity building programmes in the development of skills to identify VAW signs and symptoms, as well as provide psychological support to women/girls. There was a high acceptability of intervention among providers. Survivors also recognised the usefulness of health care facility-based support services for violence. Conclusion A multi-component intervention comprising of building capacity of providers and facility readiness is feasible to implement in low- and middle-income countries (LMIC) and can strengthen health systems' response to VAW.
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Affiliation(s)
- Shrinivas Gaddappa
- Aurangabad Government Medical College and Hospital, Aurangabad, Maharashtra India
| | - Sonali Deshpande
- Aurangabad Government Medical College and Hospital, Aurangabad, Maharashtra India
| | | | - Jyoti Rokade
- Miraj Government Medical College and Hospital, Miraj, Maharashtra India
| | - Priya Prabhu
- Miraj Government Medical College and Hospital, Miraj, Maharashtra India
| | - Sanjida Arora
- Centre for Enquiry Into Health and Allied Themes, Mumbai, India
| | - Sangeeta Rege
- Centre for Enquiry Into Health and Allied Themes, Mumbai, India
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Dowrick A, Feder G, Kelly M. Boundary-Work and the Distribution of Care for Survivors of Domestic Violence and Abuse in Primary Care Settings: Perspectives From U.K. Clinicians. QUALITATIVE HEALTH RESEARCH 2021; 31:1697-1709. [PMID: 33749389 PMCID: PMC8438775 DOI: 10.1177/1049732321998299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Health care encounters are opportunities for primary care practitioners to identify women experiencing domestic violence and abuse (DVA). Increasing DVA support in primary care is a global policy priority but discussion about DVA during consultations remains rare. This article explores how primary care teams in the United Kingdom negotiate the boundaries of their responsibilities for providing DVA support. In-depth interviews were undertaken with 13 general practitioners (GPs) in two urban areas of the United Kingdom. Interviews were analyzed thematically. Analysis focused on the boundary practices participants undertook to establish their professional remit regarding abuse. GPs maintained permeable boundaries with specialist DVA support services. This enabled ongoing negotiation of the role played by clinicians in identifying DVA. This permeability was achieved by limiting the boundaries of the GP role in the care of patients with DVA to identification, with the work of providing support distributed to local specialist DVA agencies.
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Affiliation(s)
- Anna Dowrick
- Queen Mary University of London, London, United Kingdom
| | - Gene Feder
- University of Bristol, Bristol, United Kingdom
| | - Moira Kelly
- Queen Mary University of London, London, United Kingdom
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Kielmann K, Dickson-Hall L, Jassat W, Le Roux S, Moshabela M, Cox H, Grant AD, Loveday M, Hill J, Nicol MP, Mlisana K, Black J. 'We had to manage what we had on hand, in whatever way we could': adaptive responses in policy for decentralized drug-resistant tuberculosis care in South Africa. Health Policy Plan 2021; 36:249-259. [PMID: 33582787 PMCID: PMC8059133 DOI: 10.1093/heapol/czaa147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2020] [Indexed: 11/16/2022] Open
Abstract
In 2011, the South African National TB Programme launched a policy of decentralized management of drug-resistant tuberculosis (DR-TB) in order to expand the capacity of facilities to treat patients with DR-TB, minimize delays to access care and improve patient outcomes. This policy directive was implemented to varying degrees within a rapidly evolving diagnostic and treatment landscape for DR-TB, placing new demands on already-stressed health systems. The variable readiness of district-level systems to implement the policy prompted questions not only about differences in health systems resources but also front-line actors' capacity to implement change in resource-constrained facilities. Using a grounded theory approach, we analysed data from in-depth interviews and small group discussions conducted between 2016 and 2018 with managers (n = 9), co-ordinators (n = 15), doctors (n = 7) and nurses (n = 18) providing DR-TB care. Data were collected over two phases in district-level decentralized sites of three South African provinces. While health systems readiness assessments conventionally map the availability of 'hardware', i.e. resources and skills to deliver an intervention, a notable absence of systems 'hardware' meant that systems 'software', i.e. health care workers (HCWs) agency, behaviours and interactions provided the basis of locally relevant strategies for decentralized DR-TB care. 'Software readiness' was manifest in four areas of DR-TB care: re-organization of service delivery, redressal of resource shortages, creation of treatment adherence support systems and extension of care parameters for vulnerable patients. These strategies demonstrate adaptive capacity and everyday resilience among HCW to withstand the demands of policy change and innovation in stressed systems. Our work suggests that a useful extension of health systems 'readiness' assessments would include definition and evaluation of HCW 'software' and adaptive capacities in the face of systems hardware gaps.
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Affiliation(s)
- Karina Kielmann
- Institute of Global Health and Development, Queen Margaret University, Edinburgh EH21 6UU, UK
| | - Lindy Dickson-Hall
- Division of Medical Microbiology, Faculty of Medicine, University of Cape Town, South Africa
| | | | - Sacha Le Roux
- Division of Medical Microbiology, Faculty of Medicine, University of Cape Town, South Africa
| | - Mosa Moshabela
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, South Africa
| | - Helen Cox
- Institute for Infectious Disease and Molecular Medicine and Wellcome Centre for Infectious Disease Research in Africa, University of Cape Town, Cape Town, South Africa
| | - Alison D Grant
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, South Africa
- London School of Hygiene & Tropical Medicine, TB Centre, UK
- School of Public Health, University of the Witwatersrand, South Africa
| | - Marian Loveday
- Health Systems Research Unit, South African Medical Research Council
| | - Jeremy Hill
- Division of Medical Microbiology, Faculty of Medicine, University of Cape Town, South Africa
- London School of Hygiene & Tropical Medicine, TB Centre, UK
| | - Mark P Nicol
- Division of Medical Microbiology, Faculty of Medicine, University of Cape Town, South Africa
- Infection and Immunity, School of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
| | - Koleka Mlisana
- Department of Medical Microbiology, University of KwaZulu-Natal, Durban, South Africa
| | - John Black
- Department of Infectious Diseases, Livingstone Hospital, Lindsay Rd, Industrial, Port Elizabeth, 6020, South Africa
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Bacchus LJ, Alkaiyat A, Shaheen A, Alkhayyat AS, Owda H, Halaseh R, Jeries I, Feder G, Sandouka R, Colombini M. Adaptive work in the primary health care response to domestic violence in occupied Palestinian territory: a qualitative evaluation using Extended Normalisation Process Theory. BMC FAMILY PRACTICE 2021; 22:3. [PMID: 33388033 PMCID: PMC7777212 DOI: 10.1186/s12875-020-01338-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 11/29/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND A health system response to domestic violence against women is a global priority. However, little is known about how these health system interventions work in low-and-middle-income countries where there are greater structural barriers. Studies have failed to explore how context-intervention interactions affect implementation processes. Healthcare Responding to Violence and Abuse aimed to strengthen the primary healthcare response to domestic violence in occupied Palestinian territory. We explored the adaptive work that participants engaged in to negotiate contextual constraints. METHODS The qualitative study involved 18 participants at two primary health care clinics and included five women patients, seven primary health care providers, two clinic case managers, two Ministry of Health based gender-based violence focal points and two domestic violence trainers. Semi-structured interviews were used to elicit participants' experiences of engaging with HERA, challenges encountered and how these were negotiated. Data were analysed using thematic analysis drawing on Extended Normalisation Process Theory. We collected clinic data on identification and referral of domestic violence cases and training attendance. RESULTS HERA interacted with political, sociocultural and economic aspects of the context in Palestine. The political occupation restricted women's movement and access to support services, whilst the concomitant lack of police protection left providers and women feeling exposed to acts of family retaliation. This was interwoven with cultural values that influenced participants' choices as they negotiated normative structures that reinforce violence against women. Participants engaged in adaptive work to negotiate these challenges and ensure that implementation was safe and workable. Narratives highlight the use of subterfuge, hidden forms of agency, governing behaviours, controls over knowledge and discretionary actions. The care pathway did not work as anticipated, as most women chose not to access external support. An emergent feature of the intervention was the ability of the clinic case managers to improvise their role. CONCLUSIONS Flexible use of ENPT helped to surface practices the providers and women patients engaged in to make HERA workable. The findings have implications for the transferability of evidenced based interventions on health system response to violence against women in diverse contexts, and how HERA can be sustained in the long-term.
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Affiliation(s)
- Loraine J Bacchus
- London School of Hygiene & Tropical Medicine, Department of Global Health and Development, Faculty of Public Health & Policy, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Abdulsalam Alkaiyat
- Public Health Department, An-Najah National University, Faculty of Medicine and Health Sciences, P.O. Box 7, Nablus, West Bank, Palestine.
| | - Amira Shaheen
- Public Health Department, An-Najah National University, Faculty of Medicine and Health Sciences, P.O. Box 7, Nablus, West Bank, Palestine
| | - Ahmed S Alkhayyat
- Public Health Department, An-Najah National University, Faculty of Medicine and Health Sciences, P.O. Box 7, Nablus, West Bank, Palestine
| | - Heba Owda
- Public Health Department, An-Najah National University, Faculty of Medicine and Health Sciences, P.O. Box 7, Nablus, West Bank, Palestine
| | - Rana Halaseh
- Public Health Department, An-Najah National University, Faculty of Medicine and Health Sciences, P.O. Box 7, Nablus, West Bank, Palestine
| | - Ibrahim Jeries
- Public Health Department, An-Najah National University, Faculty of Medicine and Health Sciences, P.O. Box 7, Nablus, West Bank, Palestine
| | - Gene Feder
- University of Bristol, Population Health Sciences, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Rihab Sandouka
- Juzoor for Health and Social Development, Palestine, P.O. Box 17333, Jerusalem
| | - Manuela Colombini
- London School of Hygiene & Tropical Medicine, Department of Global Health and Development, Faculty of Public Health & Policy, 15-17 Tavistock Place, London, WC1H 9SH, UK
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21
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Shaheen A, Ashkar S, Alkaiyat A, Bacchus L, Colombini M, Feder G, Evans M. Barriers to women's disclosure of domestic violence in health services in Palestine: qualitative interview-based study. BMC Public Health 2020; 20:1795. [PMID: 33243196 PMCID: PMC7691108 DOI: 10.1186/s12889-020-09907-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 11/17/2020] [Indexed: 11/23/2022] Open
Abstract
Background Domestic violence (DV) damages health and requires a global public health response and engagement of clinical services. Recent surveys show that 27% of married Palestinian women experienced some form of violence from their husbands over a 12 months' period, but only 5% had sought formal help, and rarely from health services. Across the globe, barriers to disclosure of DV have been recorded, including self-blame, fear of the consequences and lack of knowledge of services. This is the first qualitative study to address barriers to disclosure within health services for Palestinian women. Methods In-depth interviews were carried out with 20 women who had experienced DV. They were recruited from a non-governmental organisation offering social and legal support. Interviews were recorded, transcribed and translated into English and the data were analysed thematically. Results Women encountered barriers at individual, health care service and societal levels. Lack of knowledge of available services, concern about the health care primary focus on physical issues, lack of privacy in health consultations, lack of trust in confidentiality, fear of being labelled ‘mentally ill’ and losing access to their children were all highlighted. Women wished for health professionals to take the initiative in enquiring about DV. Wider issues concerned women’s social and economic dependency on their husbands which led to fears about transgressing social and cultural norms by speaking out. Women feared being blamed and ostracised by family members and others, or experiencing an escalation of violence. Conclusions Palestinian women’s agency to be proactive in help-seeking for DV is clearly limited. Our findings can inform training of health professionals in Palestine to address these barriers, to increase awareness of the link between DV and many common presentations such as depression, to ask sensitively about DV in private, reassure women about confidentiality, and increase awareness among women of the role that health services can play in DV. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-020-09907-8.
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Affiliation(s)
- Amira Shaheen
- Division of Public Health, Faculty of Medicine and Health Sciences, An Najah National University, Nablus, Palestine
| | - Suzy Ashkar
- Division of Public Health, Faculty of Medicine and Health Sciences, An Najah National University, Nablus, Palestine
| | - Abdulsalam Alkaiyat
- Division of Public Health, Faculty of Medicine and Health Sciences, An Najah National University, Nablus, Palestine
| | - Loraine Bacchus
- Faculty of Public Health & Policy, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Manuela Colombini
- Faculty of Public Health & Policy, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Gene Feder
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, Faculty of Health Sciences, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Maggie Evans
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, Faculty of Health Sciences, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
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Betron M, Thapa A, Amatya R, Thapa K, Arlotti-Parish E, Schuster A, Bhattarai J, Limbu S, Chiweshe MT, Rishal P, Dhital R. Should female community health volunteers (FCHVs) facilitate a response to gender-based violence (GBV)? A mixed methods exploratory study in Mangalsen, Nepal. Glob Public Health 2020; 16:1604-1617. [PMID: 33186506 DOI: 10.1080/17441692.2020.1839929] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
ABSTRACTAs part of a multisectoral response to gender-based violence (GBV), Nepal is testing the feasibility of having female community health volunteers (FCHVs) play a formal role in identifying GBV survivors and referring them to specialised services at health facilities. This study followed 116 FHCVs in Mangalsen municipality who attended a one-day orientation on GBV. Over the following year, data were collected from knowledge and attitude assessments of FCHVs, focus group discussions with FCHVs, and members of Mothers' Groups for Health. Most Significant Change stories were collected from FCHVs, in-depth interviews with stakeholders, and service statistics. Results show that the FCHVs' knowledge increased, attitudes changed, and confidence in addressing GBV grew. During the study period, FCHVs identified 1,253 GBV survivors and referred 221 of them to health facilities. In addition to assisting GBV survivors, FCHVs worked to prevent GBV by mediating conflicts and curbing harmful practices such as menstrual isolation. Stakeholders viewed FCHVs as a sustainable resource for identifying and referring GBV survivors to services, while women trusted them and looked to them for help. Results show that, with proper training and safety mechanisms, FCHVs can raise community awareness about GBV, facilitate support for survivors, and potentially help prevent harmful practices.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Poonam Rishal
- Dhulikhel Hospital, Kathmandu University Hospital, Kathmandu, Nepal
| | - Rolina Dhital
- Health Action and Research Lazimpat, Kathmandu, Nepal
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