Security from above and below: A critical ethnography of the health response to violence against women in Timor-Leste.

International advocacy and evidence have been critical for shifting the pervasive issue of violence against women onto the health agenda. Guidelines and training packages, however, can be underpinned by Western principles of responding to individual survivors of violence and availability of specialist referral services, which may not be available in many countries. As Timor-Leste and other nations begin to build their health system response to violence against women, it is important to understand the current practices of health providers and the broader sociocultural context of providing care to survivors of violence. During 11 months in the field (February-December 2016), we conducted qualitative interviews with 48 midwives and community leaders in three municipalities in Timor-Leste. The findings reveal that midwives engage at both the individual and collective levels, providing medical care, advice and moral support to survivors of violence as well as gathering support for women within families and communities. Midwives therefore navigate both formal and informal spaces as they respond to domestic and sexual violence. In doing so, they are influenced by their own experiences as women, as health providers imbued with authoritative knowledge, and as part of the wider sociocultural system. We argue that while much progress has been made in frameworks for health systems responding to survivors of violence, more work needs to be done to understand how to support health providers in low- and middle-income countries as they engage with perpetrators, families and communities. There is a need for further discussion of how health systems can address the issue of domestic and sexual violence as a collective social problem, while foregrounding the needs and rights of those experiencing violence. This research has implications for the content of guidelines and training, and importantly, for developing mechanisms to deal with complex social issues within local health services.

Responding to violence against women: A qualitative study with midwives in Timor-Leste.

PROBLEM: The health sector is a critical partner in the response to violence against women, but little is known about how to translate international guidelines and sustainable good practice in remote and under-resourced health systems. AIM: This research explores the barriers and enablers that midwives report in responding to domestic and sexual violence in Timor-Leste, a country with a very high rate of violence against women. The aim is to inform a systems approach to health provider training and engagement applicable to Timor-Leste and other low-resource settings. METHODS: In 2016 we conducted qualitative interviews and group discussions with 36 midwives from rural health settings, community health centres and hospitals in three municipalities of Timor-Leste. FINDINGS: A range of individual, health system and societal factors shape midwives' practice. While training provided the foundation for knowing how to respond to cases of violence, midwives still faced significant health system barriers such as lack of time, privacy and a supportive environment. Key enablers were support from colleagues and health centre managers. CONCLUSION: Health provider training to address violence against women is important but tends to focus on individual knowledge and skills. There is a need to shift toward systems-based approaches that engage all staff and managers within a health facility, work creatively to overcome barriers to implementation, and link them with wider community-based resources.

The Effectiveness of Eye Movement Desensitization and Reprocessing Therapy to Treat Symptoms Following Trauma in Timor Leste.

The effectiveness of eye movement desensitization and reprocessing (EMDR) therapy for treating trauma symptoms was examined in a postwar/conflict, developing nation, Timor Leste. Participants were 21 Timorese adults with symptoms of posttraumatic stress disorder (PTSD), assessed as those who scored ≥2 on the Harvard Trauma Questionnaire (HTQ). Participants were treated with EMDR therapy. Depression and anxiety symptoms were assessed using the Hopkins Symptom Checklist. Symptom changes post-EMDR treatment were compared to a stabilization control intervention period in which participants served as their own waitlist control. Sessions were 60-90 mins. The average number of sessions was 4.15 (SD = 2.06). Despite difficulties providing treatment cross-culturally (i.e., language barriers), EMDR therapy was followed by significant and large reductions in trauma symptoms (Cohen's d = 2.48), depression (d = 2.09), and anxiety (d = 1.77). At posttreatment, 20 (95.2%) participants scored below the HTQ PTSD cutoff of 2. Reliable reductions in trauma symptoms were reported by 18 participants (85.7%) posttreatment and 16 (76.2%) at 3-month follow-up. Symptoms did not improve during the control period. Findings support the use of EMDR therapy for treatment of adults with PTSD in a cross-cultural, postwar/conflict setting, and suggest that structured trauma treatments can be applied in Timor Leste.