Healthcare Providers' Perceptions and Experiences of Training to Respond to Violence against Women: Results from a Qualitative Study.

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.

Knowledge, attitudes and practices of health care providers trained in responding to violence against women: a pre- and post-intervention study.

BACKGROUND: Violence against women is a serious public health concern, and is highly prevalent globally, including in India. Health-care providers [HCPs] can play an important role in addressing and reducing negative consequences of violence against women. We implemented a pre-post intervention study of HCP training in three tertiary care facilities in Maharashtra, India. METHODS: The study used a pre-post intervention design with assessment of HCPs' (n = 201) knowledge, attitudes, perceived preparedness and practice at three time points: before training, after training and at 6 months follow- up. RESULTS: Total median score of knowledge about common signs and symptoms of violence (8.89 vs, 10.00), attitudes towards acceptability of violence (9.05 vs. 10.00), individual (6.74 vs. 10.00) and system level preparedness (6.11 vs. 8.14) improved from pre to post- training. The generalized estimating equation [GEE] model, adjusted for age, sex, site and department, showed an improvement in knowledge, attitudes and preparedness post- training. The change from pre to 6 months follow- up was not significant for attitude. CONCLUSIONS: This package of interventions, including training of HCPs, improved HCPs' knowledge, attitudes and practices, yet changes in attitudes and preparedness did not sustain over time. This study indicates feasibility and positive influence of a multi-component intervention to improve HCP readiness to respond to violence against women in a low-resource setting. Future phases of intervention development include adapting this intervention package for primary and secondary health facilities in this context, and future research should assess these interventions using a rigorous experimental design. Finally, these results can be used to advocate for multi-layered, systems-based approaches to strengthening health response to violence against women.

Mapping the health systems response to violence against women: key learnings from five LMIC settings (2015-2020).

BACKGROUND: Violence against women (VAW) is a global challenge, and the health sector is a key entry point for survivors to receive care. The World Health Organization adopted an earlier framework for health systems response to survivors. However, documentation on the programmatic rollout of health system response to violence against women is lacking in low and middle-income countries. This paper studies the programmatic roll out of the health systems response across select five low- and middle-income countries (LMIC) and identifies key learnings. METHODS: We selected five LMIC settings with recent or active programming on national-level health system response to VAW from 2015 to 2020. We synthesized publicly available data and program reports according to the components of the WHO Health Systems Framework. The countries selected are Bangladesh, Brazil, Nepal, Rwanda, and Sri Lanka. RESULTS: One-stop centers were found to be the dominant model of care located in hospitals in four countries. Each setting has implemented in-service training as key to addressing provider knowledge, attitudes and practice; however, significant gaps remain in addressing frequent staff turnover, provision of training at scale, and documentation of the impact of training. The health system protocols for VAW address sexual violence but do not uniformly include clinical and health policy responses for emotional or economic violence. Providing privacy to survivors within health facilities was a universal challenge. CONCLUSION: Significant efforts have been made to address provider attitudes towards provision of care and to protocolize delivery of care to survivors, primarily through one-stop centers. Further improvements can be made in data collection on training impact on provider attitudes and practices, in provider identification of VAW survivors, and in prioritization of VAW within health system budgeting, staffing, and political priorities. Primary health facilities need to provide first-line support for survivors to avoid delays in response to all forms of VAW as well as for secondary prevention.

Denial of Safe Abortion to Survivors of Rape in India.

Access to abortion is desperately needed when pregnancy is the result of rape, both within and outside marriage, and especially when a girl has been raped. The availability of services remains highly restricted because of the way abortion providers interpret the law. This paper presents the experiences of 40 rape survivors, including two children, denied an abortion following rape. The cases were recorded by CEHAT (Centre for Enquiry into Health and Allied Themes) in the course of building capacities of public hospitals to respond to violence against women in Mumbai, India, since 2000. We found that enormous damage is inflicted on women and girls by misinterpretation of the laws on abortion and rape, combined with a lack of understanding of the serious damage rape does, particularly repeated rape, and alongside other forms of assault and abuse. Domestic laws in India place a clear legal responsibility on health professionals to offer immediate care and treatment to rape survivors, including timely access to abortion. It is past due time for both the government and the courts to begin to hold themselves and health professionals accountable for ensuring this care is provided.

Integrating gender perspectives in gynecology and obstetrics: Engaging medical colleges in Maharashtra, India.

Failure to acknowledge the impact of sex and gender differences affects the quality of health care provision, and is an impediment to reducing health inequities. Systematic efforts were initiated in Maharashtra, India for reducing these disparities by developing gender-integrated curricula in undergraduate (UG) medical education between 2015 and 2018. A review of UG obstetrics and gynecology curricula indicated a lack of gender lens and focus on the reproductive rights of women. Based on these gaps, a gender-integrated curriculum was developed, implemented, and tested with medical students. Significant positive attitudes were seen among male and female students for themes such as access to safe abortion; understanding reproductive health concerns and their complex relationship with gender roles; violence against women as a health issue; and sexuality and health. These results strengthened the resolve to advocate for such a curriculum to be integrated across all medical colleges in the state.

Ethical concerns related to mandatory reporting of sexual violence.

The provision of care for survivors of sexual violence is a medico-legal emergency. However, due to social issues, healthcare providers face several ethical and legal dilemmas when administering care to such survivors at hospitals. Added to these are the compulsions under mandatory reporting laws, which oblige healthcare providers to abide by the ethical commitments of care and treatment, and make it mandatory for them to report cases of sexual violence to the police, failing which they face legal sanctions. This article draws on global evidence related to mandatory reporting of violence against women and children and the lessons learnt from it. While doing so, it presents the current status of mandatory reporting by healthcare providers in India and the challenges faced by them in operationalising the survivors' autonomy, ensuring confidentiality and overcoming obstacles that may impede treatment and care.

Gendered pattern of burn injuries in India: a neglected health issue.

There are an estimated 7 million burn injuries in India annually, of which 700,000 require hospital admission and 140,000 are fatal. According to the National Burns Programme, 91,000 of these deaths are women; a figure higher than that for maternal mortality. Women of child bearing age are on average three times more likely than men to die of burn injuries. This paper reviews the existing literature on burn injuries in India and raises pertinent issues about prevalence, causes and gaps in recognising the gendered factors leading to a high number of women dying due to burns. The work of various women's groups and health researchers with burns victims raises several questions about the categorisation of burn deaths as accident, suicide and homicide and the failure of the health system to recognise underlying violence. Despite compelling evidence, the health system has not recognised this as a priority. Considering the substantial cost of burns care, prevention is the key which requires health systems to recognise the linkages between burn injuries and domestic violence. Health systems need to integrate awareness programmes about domestic violence and train health professionals to identify signs and symptoms of violence. This would contribute to early identification of abuse so that survivors are able to access support services at an early stage.

Addressing violence against women: a call to action.

Violence against women and girls is prevalent worldwide but historically has been overlooked and condoned. Growing international recognition of these violations creates opportunities for elimination, although solutions will not be quick or easy. Governments need to address the political, social, and economic structures that subordinate women, and implement national plans and make budget commitments to invest in actions by multiple sectors to prevent and respond to abuse. Emphasis on prevention is crucial. Community and group interventions involving women and men can shift discriminatory social norms to reduce the risk of violence. Education and empowerment of women are fundamental. Health workers should be trained to identify and support survivors and strategies to address violence should be integrated into services for child health, maternal, sexual, and reproductive health, mental health, HIV, and alcohol or substance abuse. Research to learn how to respond to violence must be strengthened. The elimination of violence against women and girls is central to equitable and sustainable social and economic development and must be prioritised in the agenda for development after 2015.

Poor standards of care in small, private hospitals in Maharashtra, India: implications for public-private partnerships for maternity care.

The private health sector in India is generally unregulated. Maharashtra is among the few states which require registration of private hospitals. This paper reports on a study of standards of care in small, private hospitals (less than 30 beds) in Maharashtra state, India, with a focus on maternity care, based on interviews with the hospitals' owners or senior staff, and observation. In the absence of reliable information on the number of private hospitals in the state, a physical listing was carried out in 11 districts and an estimate drawn up; 10% of hospitals found in each location were included in the study sample. We found poor standards of care in many cases, and few or no qualified nurses or a duty medical officer in attendance. Of the 261 hospitals visited, 146 provided maternity services yet 137 did not have a qualified midwife, and though most claimed they provided emergency care, including caesarean section, only three had a blood bank and eight had an ambulance. Government plans to promote public-private partnerships with such hospitals, including for maternity services, create concern, given our findings. The need to enforce existing regulations and collect information on health outcomes and quality of care before the state involves these hospitals further in provision of maternity care is called for.