Facilitators and barriers to routine intimate partner violence screening in antenatal care settings in Uganda

Healthcare Workers' Experiences and Challenges in Managing Gender-Based Violence Among HIV-Positive Women Living in Southern, Tanzania: A Qualitative Study

Introduction

Healthcare workers (HCW) play an important role in managing women living with HIV (WLHIV) with gender-based violence (GBV) experience, but little is known about their experience in screening and managing GBV among WLHIV. This study explored the perceptions and experience of the HCWs on screening and managing GBV cases among WLHIV.

Patients and Methods

We performed a descriptive phenomenological qualitative study to elicit the views and experience of HCW on GBV screening and management for WLHIV. The study was conducted in the semi-urban setting in Morogoro Region, Tanzania. Ten in-depth interviews (IDIs) were administered to HCW selected purposefully based on their roles at an HIV care and treatment center. Data were transcribed using patterns matching study aim and then merged into relevant themes for analysis and interpretation. NVIVO software version 12 was used for data coding and analysis.

Results

We found that HCW experienced multiple challenges in GBV screening and management, including limited capacity for GBV screening and management; inadequate training on assessment and handling GBV cases, limited resources (time, GBV guidelines and screening tools), inadequate GBV referral and monitoring systems; referral forms for GBV survivors to social support centers and follow-up mechanisms to trace survivors, mental aspects; HCWs' fear of being stressed by listening to women's' GBV traumatic experiences, HCWs' fear of causing problems to the women's families and HCW biased notions on women disclosure of GBV; the believes that women will not report their GBV experiences.

Conclusion

We identified context-specific challenges preventing HCW to deliver optimal services of GBV to WLHIV, stressing the necessity to strengthen HCW capacity and resources for GBV services and to integrate psychosocial services into HIV care. Policy and programs should be developed to support GBV screening and management for WLHIV.

Implementation of gender-based violence screening guidelines in public HIV treatment programs: A mixed methods evaluation in Uganda

BACKGROUND

HIV and gender-based violence (GBV) intersect to threaten population health. The Uganda Ministry of Health recommends routine GBV screening alongside HIV care but evidence detailing its implementation in HIV care settings is limited. We evaluated screening practices in public HIV clinics to generate evidence supporting GBV screening optimization.

METHODS

To evaluate GBV screening implementation in antiretroviral therapy (ART) clinics, we extracted client data from GBV registers at 12 public ART clinics in Uganda (January 2019-December 2021). We concurrently evaluated perceptions of GBV screening/referral practices by conducting in-depth qualitative interviews with providers (N = 30) and referral partners (N = 10). We contextualized quantitative findings with interview data which were analyzed using a thematic analysis approach.

RESULTS

During the evaluation period, >90% of providers in participating health facilities implemented GBV screening. Among 107,767 clients served in public ART clinics, providers identified 9,290 (8.6%) clients who experienced past-year physical, sexual and/or emotional GBV of whom 86% received counseling and 19% were referred to support services-most commonly to legal services. Key factors influencing GBV screening implementation included awareness of screening guidelines; client volume; and client's level of engagement in HIV care. Providers and referral partners identified important benefits to clients (e.g., pursuit of justice and removal from violent environments) when referrals were successful. Key factors influencing referrals included financial constraints that limited referral partners' ability to provide services at no cost to clients and socio-cultural norms that inhibited client willingness to pursue support services.

CONCLUSIONS

GBV screening implementation in ART clinics supports identification and referral of clients exposed to violence. The effectiveness of GBV screening may be limited by socio-cultural factors that inhibit client capacity to pursue referrals and fragmented and resource-constrained referral networks. Providers and referral partners identified allocating funds to support referrals and collaborative networking meetings as important opportunities for strengthening GBV referrals.

Barriers to routine screening for intimate partner violence during pregnancy in Nigeria

Background

The benefits of routine screening for intimate partner violence (IPV) among pregnant women include early identification, prompt management, referral of IPV victims, and creating awareness about IPV. Despite these benefits, the practice of routine screening of IPV remains limited in midwifery settings in low-income countries. The purpose of this study is to identify and describe midwives' perspectives of the barriers in conducting routine screening of IPV for pregnant women in northern Nigeria.

Methods

A case study qualitative descriptive design was used to collect data from ten midwives in the antenatal clinic of a tertiary hospital. Non-participant observation and individual face-to-face semi-structured interviews were used as data collection methods. Thematic data analysis was carried out using Yin's five stage analytical cycle.

Findings

Three themes, with related subthemes, emerged from the data: (i) The theme of "Internal" barriers to IPV screening has four subthemes; midwives' personal discomfort in asking IPV- related questions, perceived mistrust of midwives by pregnant women, midwives' own perceptions of IPV as a personal matter, and midwives' lack of skills to screen for IPV. (ii) "External" barriers to IPV screening subsumes three subthemes: antenatal card related barriers, workload related barriers, and protocol barriers. (iii) "Structural" barriers to IPV screening have two subthemes: lack of space for privacy and lack of resources for managing pregnant women who have experienced IPV.

Conclusion

Knowing the barriers to midwives' screening practices is important because it may help in the development of contextually relevant and acceptable screening guidelines for midwives in Nigeria. Education and training of midwives will eliminate the internal barriers while the external barriers will need the intervention of hospital authorities and government to eliminate their effects on screening.

Adverse childhood experiences, HIV and sexual risk behaviors - Five sub-Saharan countries, 2018-2020

BACKGROUND

Adverse childhood experiences (ACEs) have been shown to have negative, lasting effects on health including increasing the likelihood of engaging in sexual risk behaviors.

OBJECTIVE

This study aimed to identify associations between exposures to ACEs and sexual risk behaviors and HIV service utilization among young people.

PARTICIPANTS AND SETTING

A sample of 8023 sexually active young people (19-24 year olds) from five sub-Saharan African countries participated Violence Against Children and Youth Surveys (VACS).

METHODS

Descriptive analysis of demographic variables, individual ACEs, cumulative ACEs, sexual risk behaviors, HIV testing, antiretroviral treatment (ART) and Antenatal Care (ANC) attendance were completed. Bivariate and multivariable logistic regression analyses were conducted to assess the associations between both individual and cumulative ACEs, sexual HIV risk behaviors, and service utilization while controlling for important covariates such as demographic, having ever been pregnant, had an STI, and used contraception.

RESULTS

Exposure to three or more ACEs was higher among males (26.1 %) compared to females (21.3 %); p = 0.003. The most prominent sexual risk behavior for females was having sexual partners who were at least 5 years older (45.7 % compared to males 3.7 %; p < 0.0001) whereas in males it was no or infrequent condom use (45.3 % compared to females 30.1 %; p < 0.0001). Males and females exposed to childhood sexual violence had seven and four times the odds of engaging in transactional sex (aOR = 7.34, 95 % CI: [3.5-15.0]) and (aOR =3.75, 95 % CI: [2.3-6.2], respectively. Females exposed to three or more ACEs were four times more likely to engage in transactional sex (aOR = 4.85, 95 %, CI: [1.6-14.4]) compared to those who did not experience any ACEs. Males exposed to three or more ACEs were two times more likely to engage in early sexual debut (aOR = 2.2, 95 % CI: [1.3-3.4]),]) compared to those who did not experience any ACEs. Females who had witnessed IPV or violence in the community had significantly higher odds of getting tested for HIV (aOR = 2.16, 95 % CI: [1.63-2.87]) and (aOR = 1.36, 95 % CI: [1.03-1.81]), respectively.

CONCLUSIONS

This study demonstrated that experiencing ACEs during childhood is associated with higher HIV risk behaviors in sub-Saharan Africa (SSA) with unique differences between males and females.

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.

Intimate partner violence and antenatal care utilization predictors in Uganda: an analysis applying Andersen's behavioral model of healthcare utilization

BACKGROUND

Optimal utilization of antenatal care (ANC) services improves positive pregnancy experiences and birth outcomes. However, paucity of evidence exists on which factors should be targeted to increase ANC utilization among women experiencing intimate partner violence (IPV) in Uganda.

OBJECTIVE

To determine the independent association between IPV exposure and ANC utilization as well as the predictors of ANC utilization informed by Andersen's Behavioral Model of Healthcare Utilization.

METHODS

We analyzed 2016 Uganda Demographic and Health Survey data that included a sample of 1,768 women with children aged 12 to 18 months and responded to both ANC utilization and IPV items. Our outcome was ANC utilization, a count variable assessed as the number of ANC visits in the last 12 months preceding the survey. The key independent variable was exposure to any IPV form defined as self-report of having experienced physical, sexual and/or emotional IPV. Covariates were grouped into predisposing (age, formal education, religion, problem paying treatment costs), enabling (women's autonomy, mass media exposure), need (unintended pregnancy, parity, history of pregnancy termination), and healthcare system/environmental factors (rural/urban residence, spatial accessibility to health facility). Poisson regression models tested the independent association between IPV and ANC utilization, and the predictors of ANC utilization after controlling for potential confounders.

RESULTS

Mean number of ANC visits (ANC utilization) was 3.71 visits with standard deviation (SD) of ± 1.5 respectively. Overall, 60.8% of our sample reported experiencing any form of IPV. Any IPV exposure was associated with lower number of ANC visits (3.64, SD ± 1.41) when compared to women without IPV exposure (3.82, SD ± 1.64) at p = 0.013. In the adjusted models, any IPV exposure was negatively associated with ANC utilization when compared to women with no IPV exposure after controlling for enabling factors (Coef. -0.03; 95%CI -0.06,-0.01), and healthcare system/environmental factors (Coef. -0.06; 95%CI -0.11,-0.04). Predictors of ANC utilization were higher education (Coef. 0.27; 95%CI 0.15,0.39) compared with no education, high autonomy (Coef. 0.12; 95%CI 0.02,0.23) compared to low autonomy, and partial media exposure (Coef. 0.06; 95%CI 0.01,0.12) compared to low media exposure.

CONCLUSION

Addressing enabling and healthcare system/environmental factors may increase ANC utilization among Ugandan women experiencing IPV. Prevention and response interventions for IPV should include strategies to increase girls' higher education completion rates, improve women's financial autonomy, and mass media exposure to improve ANC utilization in similar populations in Uganda.

Healthcare provider experiences interacting with survivors of intimate partner violence: a qualitative study to inform survivor-centered approaches

BACKGROUND

Intimate partner violence (IPV) remains a pervasive form of gender-based violence (GBV) that is largely undisclosed, especially among women seeking healthcare services in Uganda. Prioritizing survivor needs may improve IPV disclosure. This study explores healthcare worker experiences from provider-patient interactions with survivors seeking antenatal care services (ANC) in Uganda.

METHODS

In-depth interviews were conducted among twenty-eight experienced healthcare providers in a rural and an urban-based ANC clinic in Eastern and Central Uganda. Providers were asked what they viewed as the needs and fears of women identified as having experienced any form of IPV. Iterative, inductive/deductive thematic analysis was conducted to discover themes regarding perceived needs, fears, and normalizing violence experienced by IPV survivors.

RESULTS

According to healthcare providers, IPV survivors are unaware of available support services, and have need for support services. Providers reported that some survivors were afraid of the consequences of IPV disclosure namely, community stigma, worries about personal and their children's safety, retaliatory abuse, fear of losing their marriage, and partners' financial support. Women survivors also blamed themselves for IPV. Contextual factors underlying survivor concerns included the socio-economic environment that 'normalizes' violence, namely, some cultural norms condoning violence, and survivors' unawareness of their human rights due to self-blame and shame for abuse.

CONCLUSIONS

We underscore a need to empower IPV survivors by prioritizing their needs. Results highlight opportunities to create a responsive healthcare environment that fosters IPV disclosure while addressing survivors' immediate medical and psychosocial needs, and safety concerns. Our findings will inform GBV prevention and response strategies that integrate survivor-centered approaches in Uganda.

Spatial accessibility to health facilities among pregnant women with and without exposure to intimate partner violence in Uganda

BACKGROUND

Poor physical access to health facilities could increase the likelihood of undetected intimate partner violence (IPV) during pregnancy. We aimed to determine sub-regional differences and associations between spatial accessibility to health facilities and IPV among pregnant women in Uganda.

METHOD

Weighted cross-sectional analyses were conducted using merged 2016 Uganda Demographic and Health Survey and 2014 Uganda Bureau of Statistics health facility datasets. Our study population were 986 women who self-reported being currently pregnant and responded to IPV items. Outcome was spatial accessibility computed as the near point linear distance [< 5 km (optimal) vs. ≥ 5 km (low)] between women's enumeration area and health facility according to government reference cutoffs. Primary independent variable (any IPV) was defined as exposure to at least one of physical, emotional, and sexual IPV forms. Logistic regression models were sequentially adjusted for covariates in blocks based on Andersen's behavioral model of healthcare utilization. Covariates included predisposing (maternal age, parity, residence, partner controlling behavior), enabling (wealth index, occupation, education, economic empowerment, ANC visit frequency), and need (wanted current pregnancy, difficulty getting treatment money, afraid of partner, and accepted partner abuse) factors.

RESULTS

Respondents' mean age was 26.1 years with ± 9.4 standard deviations (SD), mean number of ANC visits was 3.8 (± 1.5 SD) and 492/986 (49.9%) pregnant women experienced IPV. Median spatial accessibility to the nearest health facility was 4.1 km with interquartile range (IQR) from 0.2 to 329.1 km. Southwestern, and Teso subregions had the highest average percentage of pregnant women experiencing IPV (63.8-66.6%) while Karamoja subregion had the highest median spatial accessibility (7.0 to 9.3 km). In the adjusted analysis, pregnant women exposed to IPV had significantly higher odds of low spatial accessibility to nearest health facilities when compared to pregnant women without IPV exposure after controlling for enabling factors in Model 2 (aOR 1.6; 95%CI 1.2, 2.3) and need factors in Model 3 (aOR 1.5; 95%CI 1.1, 3.8).

CONCLUSIONS

Spatial accessibility to health facilities were significantly lower among pregnant women with IPV exposure when compared to those no IPV exposure. Improving proximity to the nearest health facilities with ANC presents an opportunity to intervene among pregnant women experiencing IPV. Focused response and prevention interventions for violence against pregnant women should target enabling and need factors.