RESUMO
Background: Violence against women [VAW] is an urgent public health issue and health care providers [HCPs] are in a unique position to respond to such violence within a multi-sectoral health system response. In 2013, the World Health Organization (WHO) published clinical and policy guidelines (henceforth - the Guidelines) for responding to intimate partner violence and sexual violence against women. In this practical implementation report, we describe the adaptation of the Guidelines to train HCPs to respond to violence against women in tertiary health facilities in Maharashtra, India. Methods: We describe the strategies employed to adapt and implement the Guidelines, including participatory methods to identify and address HCPs' motivations and the barriers they face in providing care for women subjected to violence. The adaptation is built on querying health-systems level enablers and obstacles, as well as individual HCPs' perspectives on content and delivery of training and service delivery. Results: The training component of the intervention was delivered in a manner that included creating ownership among health managers who became champions for other health care providers; joint training across cadres to have clear roles, responsibilities and division of labour; and generating critical reflections about how gender power dynamics influence women's experience of violence and their health. The health systems strengthening activities included establishment of standard operating procedures [SOPs] for management of VAW and strengthening referrals to other services. Conclusions: In this intervention, standard training delivery was enhanced through participatory, joint and reflexive methods to generate critical reflection about gender, power and its influence on health outcomes. Training was combined with health system readiness activities to create an enabling environment. The lessons learned from this case study can be utilized to scale-up response in other levels of health facilities and states in India, as well as other LMIC contexts. Plain language summary: Violence against women affects millions of women globally. Health care providers may be able to support women in various ways, and finding ways to train and support health care providers in low and middle-income countries to provide high-quality care to women affected by violence is an urgent need. The WHO developed Clinical and Policy Guidelines in 2013, which provide guidance on how to improve health systems response to violence against women. We developed and implemented a series of interventions, including training of health care providers and innovations in service delivery, to implement the WHO guidelines for responding to violence against women in 3 tertiary hospitals of Maharashtra, India. The nascent published literature on health systems approaches to addressing violence against women in low and middle-income countries focuses on the impact of these interventions. This practical implementation report focuses on the interventions themselves, describes the processes of developing and adapting the intervention, and thus provides important insights for donors, policy-makers and researchers.
RESUMO
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.
RESUMO
INTRODUCTION: Better diagnosis and early referral due to increased health care coverage have increased the cesarean deliveries at tertiary-care hospitals of India. Improvements in the health care system raise many concerns and need of cross-checking system in place to counter the problems pertaining to patient education and participation of patient. While most of the cesarean sections are done in good faith for the patient, it does not escape the purview of consumer awareness and protection. MATERIALS AND METHODS: This cross-sectional study was undertaken at a tertiary level government institution to understand the level of awareness of 220 patients regarding the various aspects of cesarean delivery which are essential for women to know before giving an informed consent. RESULTS: 71 % of the women had knowledge about the indication and need to do cesarean delivery. Of these, only one-third (25 % of total women) were properly explained about procedure and complications. Other demographic and social characteristics were also evaluated. DISCUSSION: While the health care schemes have had their improved results, the onus lies upon the caregivers to improve and maintain the quality of health care in these tertiary-care government hospitals in proportion to the increase in patient load. The results of this study highlight the need for proper counseling of patients regarding complications of cesarean section. The fact that only 25 % of total cases were explained proper procedure and complication as opposed to 71 % of patients having proper knowledge about the indication of cesarean section points out the lack of information in seemingly "informed" consent. THE WAY FORWARD: To bring about awareness about the risks and complications of cesarean section, there is a need that patients be counseled during the antenatal visits, specifically when patients visit near term for antenatal check up.