Kate Joyner

Recognizing intimate partner violence in primary care: Western cape, South Africa

Introduction Interpersonal violence in South Africa is the second highest contributor to the burden of disease after HIV/AIDS and 62% is estimated to be from intimate partner violence (IPV). This study aimed to evaluate how women experiencing IPV present in primary care, how often IPV is recognized by health care practitioners and what other diagnoses are made. Methods At two urban and three rural community health centres, health practitioners were trained to screen all women for IPV over a period of up to 8 weeks. Medical records of 114 thus identified women were then examined and their reasons for encounter (RFE) and diagnoses over the previous 2-years were coded using the International Classification of Primary Care. Three focus group interviews were held with the practitioners and interviews with the facility managers to explore their experience of screening. Results IPV was previously recognized in 11 women (9.6%). Women presented with a variety of RFE that should raise the index of suspicion for IPV– headache, request for psychiatric medication, sleep disturbance, tiredness, assault, feeling anxious and depressed. Depression was the commonest diagnosis. Interviews identified key issues that prevented health practitioners from screening. Conclusion This study demonstrated that recognition of women with IPV is very low in South African primary care and adds useful new information on how women present to ambulatory health services. These findings offer key cues that can be used to improve selective case finding for IPV in resource-poor settings. Universal screening was not supported by this study.

A comprehensive model for intimate partner violence in South African primary care: action research

BackgroundDespite extensive evidence on the magnitude of intimate partner violence (IPV) as a public health problem worldwide, insubstantial progress has been made in the development and implementation of sufficiently comprehensive health services. This study aimed to implement, evaluate and adapt a published protocol for the screening and management of IPV and to recommend a model of care that could be taken to scale in our underdeveloped South African primary health care system.MethodsProfessional action research utilised a co-operative inquiry group that consisted of four nurses, one doctor and a qualitative researcher. The inquiry group implemented the protocol in two urban and three rural primary care facilities. Over a period of 14 months the group reflected on their experience, modified the protocol and developed recommendations on a practical but comprehensive model of care.ResultsThe original protocol had to be adapted in terms of its expectations of the primary care providers, overly forensic orientation, lack of depth in terms of mental health, validity of the danger assessment and safety planning process, and need for ongoing empowerment and support. A three-tier model resulted: case finding and clinical care provision by primary care providers; psychological, social and legal assistance by ‘IPV champions’ followed by a group empowerment process; and then ongoing community-based support groups.ConclusionThe inquiry process led to a model of comprehensive and intersectoral care that is integrated at the facility level and which is now being piloted in the Western Cape, South Africa.

The value of intervening for intimate partner violence in South African primary care: project evaluation

Objectives Intimate partner violence (IPV) is an important contributor to the burden of disease in South Africa. Evidence-based approaches to IPV in primary care are lacking. This study evaluated a project that implemented a South African protocol for screening and managing IPV. This article reports primarily on the benefits of this intervention from the perspective of women IPV survivors. Design This was a project evaluation involving two urban and three rural primary care facilities. Over 4–8 weeks primary care providers screened adult women for a history of IPV within the previous 24 months and offered referral to the study nurse. The study nurse assessed and managed the women according to the protocol. Researchers interviewed the participants 1 month later to ascertain adherence to their care plan and their views on the intervention. Results In total, 168 women were assisted and 124 (73.8%) returned for follow-up. Emotional (139, 82.7%), physical (115, 68.5%), sexual (72, 42.9%) and financial abuse (72, 42.9%) was common and 114 (67.9%) were at high/severe risk of harm. Adherence to the management plan ranged from testing for syphilis 10/25 (40.0%) to consulting a psychiatric nurse 28/58 (48.3%) to obtaining a protection order 28/28 (100.0%). Over 75% perceived all aspects of their care as helpful, except for legal advice from a non-profit organisation. Women reported significant benefits to their mental health, reduced alcohol abuse, improved relationships, increased self-efficacy and reduced abusive behaviour. Two characteristics seemed particularly important: the style of interaction with the nurse and the comprehensive nature of the assessment. Conclusion Female IPV survivors in primary care experience benefit from an empathic, comprehensive approach to assessing and assisting with the clinical, mental, social and legal aspects. Primary care managers should find ways to integrate this into primary care services and evaluate it further.

Implementing intimate partner violence care in a rural sub-district of South Africa: a qualitative evaluation

Background Despite a high burden of disease, in South Africa, intimate partner violence (IPV) is known to be poorly recognised and managed. To address this gap, an innovative intersectoral model for the delivery of comprehensive IPV care was piloted in a rural sub-district. Objective To evaluate the initiative from the perspectives of women using the service, service providers, and managers. Design A qualitative evaluation was conducted. Service users were interviewed, focus groups were conducted amongst health care workers (HCW), and a focus group and interviews were conducted with the intersectoral implementation team to explore their experiences of the intervention. A thematic analysis approach was used, triangulating the various sources of data. Results During the pilot, 75 women received the intervention. Study participants described their experience as overwhelmingly positive, with some experiencing improvements in their home lives. Significant access barriers included unaffordable indirect costs, fear of loss of confidentiality, and fear of children being removed from the home. For HCW, barriers to inquiry about IPV included its normalisation in this community, poor understanding of the complexities of living with violence and frustration in managing a difficult emotional problem. Health system constraints affected continuity of care, privacy, and integration of the intervention into routine functioning, and the process of intersectoral action was hindered by the formation of alliances. Contextual factors, for example, high levels of alcohol misuse and socio-economic disempowerment, highlighted the need for a multifaceted approach to addressing IPV. Conclusions This evaluation draws attention to the need to take a systems approach and focus on contextual factors when implementing complex interventions. The results will be used to inform decisions about instituting appropriate IPV care in the rest of the province. In addition, there is a pressing need for clear policies and guidelines framing IPV as a health issue.Background Despite a high burden of disease, in South Africa, intimate partner violence (IPV) is known to be poorly recognised and managed. To address this gap, an innovative intersectoral model for the delivery of comprehensive IPV care was piloted in a rural sub-district. Objective To evaluate the initiative from the perspectives of women using the service, service providers, and managers. Design A qualitative evaluation was conducted. Service users were interviewed, focus groups were conducted amongst health care workers (HCW), and a focus group and interviews were conducted with the intersectoral implementation team to explore their experiences of the intervention. A thematic analysis approach was used, triangulating the various sources of data. Results During the pilot, 75 women received the intervention. Study participants described their experience as overwhelmingly positive, with some experiencing improvements in their home lives. Significant access barriers included unaffordable indirect costs, fear of loss of confidentiality, and fear of children being removed from the home. For HCW, barriers to inquiry about IPV included its normalisation in this community, poor understanding of the complexities of living with violence and frustration in managing a difficult emotional problem. Health system constraints affected continuity of care, privacy, and integration of the intervention into routine functioning, and the process of intersectoral action was hindered by the formation of alliances. Contextual factors, for example, high levels of alcohol misuse and socio-economic disempowerment, highlighted the need for a multifaceted approach to addressing IPV. Conclusions This evaluation draws attention to the need to take a systems approach and focus on contextual factors when implementing complex interventions. The results will be used to inform decisions about instituting appropriate IPV care in the rest of the province. In addition, there is a pressing need for clear policies and guidelines framing IPV as a health issue.

Discourses and practices in institutionalised nursing in South Africa : challenges for care

ABSTRACT South African nursing remains a largely feminised and devalued profession, further undermined by the popular construction of nurses as indifferent and the healthcare systems as hindered by multiple challenges. Over the last 20 years of democracy, multiple efforts have been made at the level of policy, practice and knowledge production to address the challenges of the primary healthcare sector where nurses are such central role players. There are clearly resource challenges in South Africa which may undermine caring practices; however, this article also foregrounds the dominant discourses that shape international and local nursing, and which arguably mitigate against care that is democratic, socially responsive and sensitive to the diverse care needs of communities and individuals. Drawing on Trontos political ethics of care and on Foucauldian frameworks, the paper analyses the processes currently shaping the experience of nurses and practices of care. Key themes are the hierarchical, regulatory framework of surveillance in nursing, the dominance of biomedical discourse and the mechanistic framework that fragments nursing practice. These aspects not only disempower nurses and deny them recognition but, together with institutional disregard for the need for self-care, also reproduce a system that is inherently unable to provide humane healthcare.

Emergency care provision for, and psychological distress in, survivors of domestic violence

Abstract BackgroundThis study aimed (i) to ascertain the number of treatment referrals and information about protection orders given to survivors of domestic violence presenting for emergency trauma care, as reported at the one-month visit, (ii) to obtain a profile of violent incidents and injuries, and (iii) to assess self-esteem and posttraumatic and depressive symptomatology in the aftermath of injury. MethodsA survey of 62 participants presenting in the acute aftermath of domestic violence (as defined by the Domestic Violence Act of 1998) was conducted over 12 weeks at the Trauma and Resuscitation Unit of a Level One trauma centre in an urban public hospital in South Africa.1 Following informed consent, face-to-face structured interviews were conducted during admission and a month later. The following instruments were administered at baseline: a Demographic and Injury Questionnaire, the Beck Depression and Rosenberg Self-Esteem Inventories, and the Davidson Trauma Scale. A psychosocial questionnaire was administered at the one- month follow-up. ResultsFifty-eight per cent of the participants were female and 42% were male. Seventy-four per cent of the perpetrators were male. Ninety-five per cent of the participants said that no health professional had informed them about where or how they could find help. Although all were seriously injured, 76% of the participants said only the researcher had asked about their experience. Sixty-six per cent of the cases of domestic violence were related to intimate partner violence. Overall, subjects displayed high levels of depressive and posttraumatic stress symptomatology that had neither been treated nor adequately referred. ConclusionEven though domestic violence poses significant health threats and costs to the health system, it appears to be a neglected area of South African health care. Health professionals should at least be able to identify and intervene within the “open window” period when psychosocial opportunities are pivotal.

Health sector responses to intimate partner violence: A literature review

Abstract Background Intimate partner violence (IPV) is a common and serious public health concern, particularly in South Africa, but it is not well managed in primary care. Aim This review aims to summarise the current state of knowledge regarding health sector-based interventions for IPV, their integration into health systems and services and the perspectives of service users and healthcare workers on IPV care, focusing on the South African context. Method PubMed, CINAHL, PsycINFO and Google Scholar were searched between January 2012 and May 2014. All types of study design were included, critically appraised and summarised. Results Exposure to IPV leads to wide-ranging and serious health effects. There is sufficient evidence that intervening in IPV in primary care can improve outcomes. Women who have experienced IPV have described an appropriate response by healthcare providers to be non-judgmental, understanding and empathetic. IPV interventions that are complex, comprehensive and utilise systems-wide approaches have been most effective, but system- and society-level barriers hamper implementation. Gender inequities should not be overlooked when responding to IPV. Conclusion Further evaluations of health sector responses to IPV are needed, in order to assist health services to determine the most appropriate models of care, how these can be integrated into current systems and how they can be supported in managing IPV. The need for this research should not prevent health services and healthcare providers from implementing IPV care, but rather should guide the development of rigorous contextually-appropriate evaluations.

Quality of care for intimate partner violence in South African primary care: a qualitative study

Intimate partner violence (IPV) makes a substantial contribution to the burden of disease in South Africa. This article explores the current quality of care for IPV in public sector primary care facilities within the Western Cape. Only 10% of women attending primary care, while suffering from IPV, were recognized. Case studies, based on in-depth interviews and medical records, were used to reflect on the quality of care received among the women who were recognized. Care tended to be superficial, fragmented, poorly coordinated, and lacking in continuity. The recognition, management, and appropriate documentation of IPV should be prioritized within the training of primary care providers. It may be necessary to appoint IPV champions within primary care to ensure comprehensive care for survivors of IPV.

Sexual assault survivors’ perspectives on clinical follow-up in the Eden District, South Africa: A qualitative study

Background Although effective follow-up of sexual assault survivors is linked to optimal recovery, attendance at follow-up consultations is poor. It is therefore essential that health care providers maximise the benefit of follow-up care for every sexual assault survivor. Aim This study explored the personal experiences of sexual assault survivors to better understand the enablers of, and barriers to, attendance at follow-up consultations. Methods This phenomenological qualitative study was conducted at the three hospitals which manage most sexual assault survivors within the Eden District. Using purposive sampling, 10 participants were selected. Consenting participants shared their experiences during semi-structured interviews with the researcher. Results Authoritative, client-held documentation was a powerful enabler to accessing follow-up care. Individualised, patient-centred care further enhanced participants’ access to, and utilisation of, health care services. The failure of health care providers to integrate follow-up care for sexual assault survivors into established chronic care services was a missed opportunity in the continuum of care. Negative perceptions, based on others’ or personal prior experience of police, judicial and health care systems, were further barriers to follow-up care. Conclusion This study highlights the need of survivors of sexual assault for integrated, patient-centred care, encompassing principles of good communication. Committed actions of all stakeholders are necessary to tackle negative perceptions that create barriers to follow-up care. A simple practical strategy, the provision of a scheduled appointment on official stationery, is easy to effect at facility level. As a powerful enabler to follow-up care, this should be implemented as a priority intervention.

Prevalence of intimate partner violence and associated factors amongst women attending antenatal care at Outapi clinic, Namibia: A descriptive survey

Background Intimate partner violence (IPV) is a significant and largely hidden public health problem for all women and, during pregnancy, can have significant effects on the health of both mother and the unborn baby. Previous Namibian studies suggest rates of IPV as high as 36%, although few studies have been conducted in primary care. Aim To determine the prevalence of IPV amongst women attending antenatal care. Setting Outapi primary care clinic, Namibia. Methods A descriptive survey administering a validated questionnaire to 386 consecutive participants. Results The mean age of the participants was 27.5 years (standard deviation = 6.8), 335 (86.8%) were unmarried, 215 (55.7%) had only primary school education and 237 (61.4%) were in their third trimester. Overall, 51 participants (13.2%) had HIV and 44 (11.4%) had teenage pregnancies. The reported lifetime prevalence of IPV was 39 (10.1%), the 12-month prevalence was 35 (9.1%) and the prevalence during pregnancy was 31 (8.0%). Emotional abuse was the commonest type of abuse in 27 (7.0%). The commonest specific abusive behaviour was refusing to provide money to run the house or look after the children whilst the partner spent money on his priorities (4.9%). Increased maternal age was associated with an increase in the occurrence of IPV. Conclusion The reported lifetime prevalence of IPV was 10.1%, with emotional abuse being the commonest type of abuse. Increased age was associated with an increase in reported IPV. IPV is significant enough to warrant that healthcare providers develop guidelines to assist women affected by IPV in Namibia.