Manuela Colombini

The health-systems response to violence against women

Health systems have a crucial role in a multisector response to violence against women. Some countries have guidelines or protocols articulating this role and health-care workers are trained in some settings, but generally system development and implementation have been slow to progress. Substantial system and behavioural barriers exist, especially in low-income and middle-income countries. Violence against women was identified as a health priority in 2013 guidelines published by WHO and the 67th World Health Assembly resolution on strengthening the role of the health system in addressing violence, particularly against women and girls. In this Series paper, we review the evidence for clinical interventions and discuss components of a comprehensive health-system approach that helps health-care providers to identify and support women subjected to intimate partner or sexual violence. Five country case studies show the diversity of contexts and pathways for development of a health system response to violence against women. Although additional research is needed, strengthening of health systems can enable providers to address violence against women, including protocols, capacity building, effective coordination between agencies, and referral networks.

Study protocol for the Integra Initiative to assess the benefits and costs of integrating sexual and reproductive health and HIV services in Kenya and Swaziland.

BackgroundIn sub-Saharan Africa (SSA) there are strong arguments for the provision of integrated sexual and reproductive health (SRH) and HIV services. Most HIV transmissions are sexually transmitted or associated with pregnancy, childbirth, and breastfeeding. Many of the behaviours that prevent HIV transmission also prevent sexually transmitted infections and unintended pregnancies. There is potential for integration to increase the coverage of HIV services, as individuals who use SRH services can benefit from HIV services and vice-versa, as well as increase cost-savings. However, there is a dearth of empirical evidence on effective models for integrating HIV/SRH services. The need for robust evidence led a consortium of three organizations – International Planned Parenthood Federation, Population Council and the London School of Hygiene & Tropical Medicine – to design/implement the Integra Initiative. Integra seeks to generate rigorous evidence on the feasibility, effectiveness, cost and impact of different models for delivering integrated HIV/SRH services in high and medium HIV prevalence settings in SSA.Methods/designA quasi-experimental study will be conducted in government clinics in Kenya and Swaziland – assigned into intervention/comparison groups. Two models of service delivery are investigated: integrating HIV care/treatment into 1) family planning and 2) postnatal care. A full economic-costing will be used to assess the costs of different components of service provision, and the determinants of variations in unit costs across facilities/service models. Health facility assessments will be conducted at four time-periods to track changes in quality of care and utilization over time. A two-year cohort study of family planning/postnatal clients will assess the effect of integration on individual outcomes, including use of SRH services, HIV status (known/unknown) and pregnancy (planned/unintended). Household surveys within some of the study facilities’ catchment areas will be conducted to profile users/non-users of integrated services and demand/receipt of integrated services, before-and-after the intervention. Qualitative research will be conducted to complement the quantitative component at different time points. Integra takes an embedded ‘programme science’ approach to maximize the uptake of findings into policy/practice.DiscussionIntegra addresses existing evidence gaps in the integration evaluation literature, building on the limited evidence from SSA and the expertise of its research partners.Trial registrationCurrent Controlled Trials NCT01694862

Bridging the gaps: a global review of intersections of violence against women and violence against children

Background The international community recognises violence against women (VAW) and violence against children (VAC) as global human rights and public health problems. Historically, research, programmes, and policies on these forms of violence followed parallel but distinct trajectories. Some have called for efforts to bridge these gaps, based in part on evidence that individuals and families often experience multiple forms of violence that may be difficult to address in isolation, and that violence in childhood elevates the risk of violence against women. Methods This article presents a narrative review of evidence on intersections between VAC and VAW – including sexual violence by non-partners, with an emphasis on low- and middle-income countries. Results We identify and review evidence for six intersections: 1) VAC and VAW have many shared risk factors. 2) Social norms often support VAW and VAC and discourage help-seeking. 3) Child maltreatment and partner violence often co-occur within the same household. 4) Both VAC and VAW can produce intergenerational effects. 5) Many forms of VAC and VAW have common and compounding consequences across the lifespan. 6) VAC and VAW intersect during adolescence, a time of heightened vulnerability to certain kinds of violence. Conclusions Evidence of common correlates suggests that consolidating efforts to address shared risk factors may help prevent both forms of violence. Common consequences and intergenerational effects suggest a need for more integrated early intervention. Adolescence falls between and within traditional domains of both fields and deserves greater attention. Opportunities for greater collaboration include preparing service providers to address multiple forms of violence, better coordination between services for women and for children, school-based strategies, parenting programmes, and programming for adolescent health and development. There is also a need for more coordination among researchers working on VAC and VAW as countries prepare to measure progress towards 2030 Sustainable Development Goals.Background The international community recognises violence against women (VAW) and violence against children (VAC) as global human rights and public health problems. Historically, research, programmes, and policies on these forms of violence followed parallel but distinct trajectories. Some have called for efforts to bridge these gaps, based in part on evidence that individuals and families often experience multiple forms of violence that may be difficult to address in isolation, and that violence in childhood elevates the risk of violence against women. Methods This article presents a narrative review of evidence on intersections between VAC and VAW - including sexual violence by non-partners, with an emphasis on low- and middle-income countries. Results We identify and review evidence for six intersections: 1) VAC and VAW have many shared risk factors. 2) Social norms often support VAW and VAC and discourage help-seeking. 3) Child maltreatment and partner violence often co-occur within the same household. 4) Both VAC and VAW can produce intergenerational effects. 5) Many forms of VAC and VAW have common and compounding consequences across the lifespan. 6) VAC and VAW intersect during adolescence, a time of heightened vulnerability to certain kinds of violence. Conclusions Evidence of common correlates suggests that consolidating efforts to address shared risk factors may help prevent both forms of violence. Common consequences and intergenerational effects suggest a need for more integrated early intervention. Adolescence falls between and within traditional domains of both fields and deserves greater attention. Opportunities for greater collaboration include preparing service providers to address multiple forms of violence, better coordination between services for women and for children, school-based strategies, parenting programmes, and programming for adolescent health and development. There is also a need for more coordination among researchers working on VAC and VAW as countries prepare to measure progress towards 2030 Sustainable Development Goals.

Access of Roma to sexual and reproductive health services: Qualitative findings from Albania, Bulgaria and Macedonia

Abstract The purpose of this study was to explore access of Roma in South-Eastern Europe to sexual and reproductive health services. We conducted 7 focus group discussions with a total of 58 participants from Roma communities in Albania, Bulgaria and Macedonia. Our study revealed a number of barriers for Roma when accessing sexual and reproductive health services. Among the most important were the overall lack of financial resources, requests by health care providers for informal payments, lack of health insurance and geographical barriers. Health systems in the region seem to have failed to provide financial protection and equitable services to one of the most vulnerable groups of society. There is also a need for overcoming racial discrimination, improving awareness and information and addressing gender inequalities.

An integrated health sector response to violence against women in Malaysia: lessons for supporting scale up

BackgroundMalaysia has been at the forefront of the development and scale up of One-Stop Crisis Centres (OSCC) - an integrated health sector model that provides comprehensive care to women and children experiencing physical, emotional and sexual abuse. This study explored the strengths and challenges faced during the scaling up of the OSCC model to two States in Malaysia in order to identify lessons for supporting successful scale-up.MethodsIn-depth interviews were conducted with health care providers, policy makers and key informants in 7 hospital facilities. This was complemented by a document analysis of hospital records and protocols. Data were coded and analysed using NVivo 7.ResultsThe implementation of the OSCC model differed between hospital settings, with practise being influenced by organisational systems and constraints. Health providers generally tried to offer care to abused women, but they are not fully supported within their facility due to lack of training, time constraints, limited allocated budget, or lack of referral system to external support services. Non-specialised hospitals in both States struggled with a scarcity of specialised staff and limited referral options for abused women. Despite these challenges, even in more resource-constrained settings staff who took the initiative found it was possible to adapt to provide some level of OSCC services, such as referring women to local NGOs or community support groups, or training nurses to offer basic counselling.ConclusionsThe national implementation of OSCC provides a potentially important source of support for women experiencing violence. Our findings confirm that pilot interventions for health sector responses to gender based violence can be scaled up only when there is a sound health infrastructure in place – in other words a supportive health system. Furthermore, the successful replication of the OSCC model in other similar settings requires that the model – and the system supporting it – needs to be flexible enough to allow adaptation of the service model to different types of facilities and levels of care, and to available resources and thus better support providers committed to delivering care to abused women.

Experiences of health care providers with integrated HIV and reproductive health services in Kenya: a qualitative study.

BackgroundThere is broad consensus on the value of integration of HIV services and reproductive health services in regions of the world with generalised HIV/AIDS epidemics and high reproductive morbidity. Integration is thought to increase access to and uptake of health services; and improves their efficiency and cost-effectiveness through better use of available resources. However, there is still very limited empirical literature on health service providers and how they experience and operationalize integration. This qualitative study was conducted among frontline health workers to explore provider experiences with integration in order to ascertain their significance to the performance of integrated health facilities.MethodsSemi-structured in-depth interviews were conducted with 32 frontline clinical officers, registered nurses, and enrolled nurses in Kitui district (Eastern province) and Thika and Nyeri districts (Central province) in Kenya. The study was conducted in health facilities providing integrated HIV and reproductive health services (post-natal care and family planning). All interviews were conducted in English, transcribed and analysed using Nvivo 8 qualitative data analysis software.ResultsProviders reported delivering services in provider-level and unit-level integration, as well as a combination of both. Provider experiences of actual integration were mixed. At personal level, providers valued skills enhancement, more variety and challenge in their work, better job satisfaction through increased client-satisfaction. However, they also felt that their salaries were poor, they faced increased occupational stress from: increased workload, treating very sick/poor clients, and less quality time with clients. At operational level, providers reported increased service uptake, increased willingness among clients to take an HIV test, and reduced loss of clients. But the majority also reported infrastructural and logistic deficiencies (insufficient physical room space, equipment, drugs and other medical supplies), as well as increased workload, waiting times, contact session times and low staffing levels.ConclusionsThe success of integration primarily depends on the performance of service providers which, in turn, depends on a whole range of facilitative organisational factors. The central Ministry of Health should create a coherent policy environment, spearhead strategic planning and ensure availability of resources for implementation at lower levels of the health system. Health facility staffing norms, technical support, cost-sharing policies, clinical reporting procedures, salary and incentive schemes, clinical supply chains, and resourcing of health facility physical space upgrades, all need attention. Yet, despite these system challenges, this study has shown that integration can have a positive motivating effect on staff and can lead to better sharing of workload - these are important opportunities that deserve to be built on.

Exploring risk of experiencing intimate partner violence after HIV infection: a qualitative study among women with HIV attending postnatal services in Swaziland

Objective To explore risks of experiencing intimate partner violence (IPV) after HIV infection among women with HIV in a postnatal care setting in Swaziland. Design A qualitative semistructured in-depth interview study, using thematic analysis with deductive and inductive coding, of IPV experiences after HIV infection extracted from service-integration interview transcripts. Setting Swaziland. Participants 19 women with HIV, aged 18–44, were purposively sampled for an in-depth interview about their experiences of services, HIV and IPV from a quantitative postnatal cohort participating in an evaluation of HIV and reproductive health services integration in Swaziland. Results Results indicated that women were at risk of experiencing IPV after HIV infection, with 9 of 19 disclosing experiences of physical violence and/or coercive control post-HIV. IPV was initiated through two key pathways: (1) acute interpersonal triggers (eg, status disclosure, mother-to-child transmission of HIV) and (2) chronic normative tensions (eg, fertility intentions, initiating contraceptives). Conclusions The results highlight a need to mitigate the risk of IPV for women with HIV in shorter and longer terms in Swaziland. While broader changes are needed to resolve gender disparities, practical steps can be institutionalised within health facilities to reduce, or avoid increasing, IPV pathways for women with HIV. These might include mutual disclosure between partners, greater engagement of Swazi males with HIV services, and promoting positive masculinities that support and protect women. Trial registration number NCT01694862.

The risks of partner violence following HIV status disclosure, and health service responses: narratives of women attending reproductive health services in Kenya.

For many women living with HIV (WLWH), the disclosure of positive status can lead to either an extension of former violence or new conflict specifically associated with HIV status disclosure. This study aims to explore the following about WLWH: 1. the womens experiences of intimate partner violence (IPV) risks following disclosure to their partners; 2. an analysis of the womens views on the role of health providers in preventing and addressing IPV, especially following HIV disclosure.

Experiences of stigma among women living with HIV attending sexual and reproductive health services in Kenya: a qualitative study

BackgroundResearchers have widely documented the pervasiveness of HIV stigma and discrimination, and its impact on people living with HIV. Only a few studies, however, have analysed the perceptions of women living with HIV accessing sexual and reproductive health (SRH) services. This study explores the experiences of stigma of HIV-positive clients attending family planning and post-natal services and implications for service use and antiretroviral therapy (ART) adherence. Our aim was to gain a better understanding of the impact of various dimensions of stigma on service use and ART adherence among HIV clients in order to inform the response of integrated SRH services.MethodsIn-depth interviews were conducted with 48 women living with HIV attending SRH services in two districts in Kenya. Data were coded using Nvivo 8 and analysed using a thematic analysis approach.ResultsFindings show that many women living with HIV report high levels of anticipated stigma, resulting in a desire to hide their status from family and friends for fear of being discriminated against. Many women feared desertion following disclosure of their positive status to partners. Consequently some women preferred to hide their status and adhere to HIV treatment in secret. However, the majority of study participants attending postnatal care (PNC) services also revealed that anticipated stigma does not adversely affect their HIV drug uptake and ART adherence, as their drive to live outweighs their fear of stigma. Our findings also seem to suggest a preference for specialist HIV services by some family planning (FP) clients because of better confidentiality and reduced opportunities for unwanted disclosure that could lead to stigma.ConclusionsThe findings highlight that anticipated stigma leading to low disclosure is widespread and sometimes reinforced by health providers’ actions and facility layout (contributing to enacted stigma). However, the motivation to stay healthy and look after the children appears in many cases to override fears of stigma related to ART adherence in our client-based sample.

Factors affecting adherence to short-course ARV prophylaxis for preventing mother-to-child transmission of HIV in sub-Saharan Africa: a review and lessons for future elimination

Despite the biomedical potential to eliminate vertical HIV transmission, drug adherence to short regimens is often sub-optimal. To inform future programmes, we reviewed evidence on the factors influencing maternal and infant drug adherence to preventing MTCT drug regimens at delivery in sub-Saharan Africa. A literature review yielding 14 studies on adherence to drug regimes among HIV-positive pregnant women and mothers in sub-Saharan Africa was conducted. Rates of maternal adherence to preventive drug regimens at time of delivery varied widely across sites between 35 and 93.5%. Factors most commonly associated with low adherence to antiretroviral therapy (ARV) prophylaxis for preventing MTCT at the health system level include giving birth at home, quality and timing of HIV testing and counselling, and late distribution of nevirapine (NVP). Socio-demographic and demand-side factors include fear of stigma, lack of male involvement, fear of partners reaction to disclosure, few antenatal (ANC) visits, young age and lack of education. With the implementation of the newly published WHO guidelines recommending triple-drug ARV regimen during pregnancy and breastfeeding for all women with HIV, it is important that women are able to adhere to recommended drug regimens. Service improvements should include clear and timely communication with women about the benefits of combined regimens and greater emphasis on patient confidentiality. Efforts must be made to help women overcome barriers that reduce adherence, such as financial logistical challenges, social stigma and womens fear of violence.