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Intervention improves the healthcare response to domestic violence in low- and middle-income countries

Training to Nepalese healthcare providers

Training being given to Nepalese healthcare providers

Press release issued: 27 November 2024

Culturally appropriate women-centred interventions can help healthcare systems respond to domestic violence, research has found. HERA (Healthcare Responding to Violence and Abuse) has been co-developing and evaluating a domestic violence and abuse healthcare intervention in low- and middle-income countries for the past five years. This National Institute for Health and Care Research (NIHR) Global Research Group will report their findings, and publish a PolicyBristol report, at a conference in London today [27 November].

The Group was co-led by the University of Bristol and London School of Hygiene & Tropical Medicine. Specific country studies were led by the University of Sao Paulo (Brazil), Kathmandu University (Nepal), An-Najah National University (occupied Palestinian territories), and University of Peradeniya (Sri Lanka). Domestic violence and abuse (DVA) against women is a significant concern in each of these countries, with a prevalence of 23 per cent in Brazil, 27 per cent in Nepal, 29 per cent in the occupied Palestinian territories (oPt), and 24 per cent in Sri Lanka.

Following implementation of the HERA programme, rates of identification of DVA in participating health services increased by 78 per cent in Brazil, 100 per cent in Nepal and 69 per cent in Sri Lanka1. There was a 24 per cent decrease in identification of women experiencing DVA in the oPt, partly due to escalating violence in the Israeli occupation2.

Healthcare worker confidence and motivation to address domestic violence improved, with healthcare workers reporting increases in their readiness to identify, inquire about and respond to domestic violence by documenting cases, making referrals, and offering ongoing support. In Nepal, there was a slight decrease in healthcare worker confidence to offer ongoing support due to the healthcare clinics becoming Covid isolation wards.

Context matters 

HERA aimed to strengthen each country’s health system response to DVA by focusing on women-centred care, context-specific adaptations, and healthcare leadership to drive change. It was informed by World Health Organization clinical guidance. The study took place in health services serving socioeconomically disadvantaged communities, focusing on sexual and reproductive health care. This included primary healthcare facilities in Brazil, Nepal, and the oPt, as well as in district general hospitals in Sri Lanka.

Key elements of the intervention were:

  • training, which focused on: enhancing understanding of women's experiences, building skills for empathy, asking questions in a non-judgmental manner, and providing first-line support
  • improving recording practices
  • establishing care pathways for affected women within and beyond the health system

The adaptation and implementation of HERA in the four countries was shaped by their distinct socio-cultural, political and economic contexts. This included issues such as: drug cartel activities in Brazil and social violence relating to the Israeli occupation of the West Bank2; gender norms and variations in laws regarding violence against women; and challenges posed by the COVID-19 pandemic.

Impact 

Training has been vital to address domestic violence in the four countries.

  • In Brazil, the south region hopes to expand HERA training to all services in that region, including health services other than primary healthcare (mental health and emergency services, specially). 
  • The Palestinian Ministry of Health will invite healthcare providers who participated in the "Train the Trainer" programme to train their colleagues in future gender-based violence training sessions. 
  • The training material developed and used for the HERA intervention in Sri Lanka - to increase awareness and response to DVA among healthcare professionals (HCPs) -  has been discussed with the Family Health Bureau (FHB) of the Ministry of Health.  It is hoped the material will be used in their HCP training program in 2025.
  • The HERA team in Nepal was instrumental in advocating for a Gender Transformative Approach (GTA) to train healthcare providers along with the United Nations Population Fund (UNFPA). Currently, the governmental training manual on healthcare response to GBV is being revised to incorporate GTA. The HERA team will train providers/medical students/nursing students/physiotherapy students from different departments and institutions to use the GTA approach.    

Recommendations 

The report makes a number of policy and practice recommendations, which include:

  • Strengthen health system linkages with local leaders, women’s organisations and non-governmental organisation (NGO)-led services
  • Incorporate a robust women-centred perspective in training programmes, grounded in an understanding of gender inequality
  • Develop targeted interventions for managers to drive organisational change
  • Expand referral options for women at various stages of readiness to seek help
  • Maintain a simple, unified record system for documenting DVA
  • Establish targets and performance indicators for DVA responses in healthcare systems

Gene Feder, Professor of Primary Care in the Centre for Academic Primary Care at the University of Bristol and co-Director of HERA, said: “Violence against women is a severe violation of human rights rooted in gender and economic inequalities, affecting nearly one in three women globally. The rates are even higher in some low- and middle-income countries. Health systems play a crucial role in addressing the immediate health needs of women and supporting their pathways to safety and recovery. In HERA we found that health systems in diverse countries in the global South could be strengthened to identify and respond to the needs of women experiencing domestic violence.”

Loraine Bacchus, Professor of Global Public Health at the London School of Hygiene & Tropical Medicine and co-Director of HERA, explained: “HERA has shown that culturally appropriate, women-centred programmes can strengthen healthcare system responses to domestic violence. By collaborating with local health services and addressing the specific challenges faced by their local communities, it is possible to improve healthcare worker confidence and build trust with the women they support. This work highlights the value of country-specific strategies to improve how doctors and other healthcare workers respond to violence against women.”

Professor Ana Flavia d’Oliveira, Principal Investigator, University of São Paulo, said:” Our greatest achievement and the true success of the HERA intervention lie in increasing the identification of domestic violence cases without resorting to mechanical questions or obtaining irrelevant answers. This increase signifies a more attentive and perceptive approach toward women, with a deeper understanding of gender, race, and class inequalities. It also fosters the belief in shared decision-making.

“Primary care's role in supporting these cases is crucial, serving as an entry point to the rights protection network, despite its limitations. HERA has developed an approach to posing questions, providing support, and making referrals that avoids judgment and re-victimisation. Instead of viewing patients as helpless, it recognises women as empowered individuals capable of making decisions and accepting their consequences.”

Amira Shaheen, Assistant Professor and Principal Investigator, An Najah National University said: "We are deeply committed to advancing healthcare responses to abuse and violence. This initiative not only seeks to strengthen the capacity of our healthcare systems but also to provide a lifeline for those affected. Our work reflects the resilience of communities and the critical role of healthcare in safeguarding human dignity and well-being."

Dr Poonam Rishal, Principal Investigator, Kathmandu University, said: “HERA Nepal has been a collaborative journey to contribute to meaningful work aligning with our passion for fostering change for women who experience violence and abuse. It has been a learning of best practices and challenging existing research that can support policy implementation and amplify voices of women, enriching professional and personal development. Camaraderie, transparency and non-hierarchical leadership were pivotal to its success.”

Professor Thilini Rajapakse, Principal Investigator, University of Peradeniya, said: “Our main aim is to improve the healthcare response to domestic violence, and to increase awareness about this key issue.  We also strongly advocate for improving support and service provision for people experiencing domestic violence, and exploring socio-culturally appropriate ways to do so. HERA has been an important part of our programme.”

This research was funded by the NIHR (17/63/125) using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the UK Government. The views expressed in this article are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

PolicyBristol report  

Health system interventions can improve domestic violence support but context matters’ by  Loraine J Bacchus, Manuela Colombini (London School of Hygiene & Tropical Medicine), Stephanie Pereira, Ana Flavia d’Oliveira, Lilia Blima Schraiber (University of São Paulo), Poonam Rishal, Kunta Pun (Kathmandu University), Thilini Rajapakse (University of Peradeniya), Amira Shaheen, Abdulsalam Alkaiyat (An-Najah National University), Claudia Garcia Moreno (World Health Organization), Gene Feder (University of Bristol) by PolicyBristol

Papers

Healthcare professionals' own experiences of domestic violence and abuse: a meta-analysis of prevalence and systematic review of risk markers and consequences by Dheensa S, McLindon E, Spencer C et al. in Trauma Violence Abuse

‘Interventions in sexual and reproductive health services addressing violence against women in low-income and middle-income countries: a mixed-methods systematic review by Lewis NV, Munas M, Colombini M, et al. in BMJ Open

Barriers to help-seeking from healthcare professionals amongst women who experience domestic violence - a qualitative study in Sri Lanka’ by Silva, T, Agampodi, T, Evans, M. et al. in BMC Public Health

Engaging early career researchers in a global health research capacity-strengthening programme: a qualitative study‘ by Hawcroft C, Rossi E, Tilouche N et al in Health Research Policy and Systems

Evaluation of an intervention to improve Primary Health Care’s response to cases of domestic violence against women - São Paulo, Brazil‘ by Pereira S, Azeredo YN Schraiber, LB et al. in Ciência & Saúde Coletiva 

Ethical challenges in global research on health system responses to violence against women: a qualitative study of policy and professional perspectives‘ by Lewis NV, Kalichman B, Azeredo et al. in BMC Medical Ethics

Comparing health systems readiness for integrating domestic violence services in Brazil, occupied Palestinian Territories, Nepal and Sri Lanka’ by Colombini M, Shrestha S, Kalichman B et al. in Health Policy and Planning

Interventions that prevent or respond to intimate partner violence against women and violence against children: a systematic review‘ by Bacchus LJ, Colombini M, Pearson I et al. in Lancet Public Health

Evaluation of a domestic violence training and support intervention in Palestinian primary care clinics: a mixed method study‘ by Joudeh N, Shaheen A, Bacchus LJ et al. in BMC Primary Care

Further information

1Documentation of DVA cases identified before and after HERA 

Studied Country

Before

After

Brazila

81

144

Nepalb

0

38

oPtc

74

56

Sri Lankad

167

283

Sources: a) Epidemiological Surveillance data based on 12 months before (Region 1: Nov/2018 to Oct/2019, and Region 2: Sep/19 to Aug/20) and after intervention (Region 1: Nov/19 to Oct/20, and Region 2: Sep/20 to Aug/21); 

  1. b) Government paper-based documentation system in place at Dhulikhel Hospital before HERA. This system was later converted into an Excel version for use at the ORCs during HERA. Post-intervention figure was based on C-ACASI and the Excel register implemented as part of HERA based on 7 months (Aug/21 to Feb/22) after intervention implementation; 
  2. c) Ministry of Health clinics’ registries, with pre-intervention figure representing 22 months before (Jan/19 to Oct/20) and 23 months post-intervention (Sept/20 to July/22);
  3. d) Before and after figures based on self-reported pre and post PIM, based on 6 months before (Hospital 1: Jul to Dec/20  and Hospital 2: Aug/20 to Jan/21 ) and after intervention (Hospital 1: Jan to June/21 , and Hospital 2: Feb to July/21).

Study sites and intervention features

Brazil

Nepal

oPt

Sri Lanka

Number of health services

8

5

4

2

16 Days of Activism against Gender-Based Violence 
The 16 Days of Activism against Gender-Based Violence is an annual international campaign that starts on 25 November, the International Day for the Elimination of Violence against Women, and runs until 10 December, Human Rights Day.

2Based on data collected in 2021 and 2022.

About the National Institute for Health and Care Research (NIHR)
The mission of the National Institute for Health and Care Research (NIHR) is to improve the health and wealth of the nation through research. We do this by:

  • Funding high quality, timely research that benefits the NHS, public health and social care;
  • Investing in world-class expertise, facilities and a skilled delivery workforce to translate discoveries into improved treatments and services;
  • Partnering with patients, service users, carers and communities, improving the relevance, quality and impact of our research;
  • Attracting, training and supporting the best researchers to tackle complex health and social care challenges;
  • Collaborating with other public funders, charities and industry to help shape a cohesive and globally competitive research system;
  • Funding applied global health research and training to meet the needs of the poorest people in low- and middle-income countries.

NIHR is funded by the Department of Health and Social Care. Its work in low and middle income countries is principally funded through UK Aid from the UK government.

About the Centre for Academic Primary Care, University of Bristol
The Centre for Academic Primary Care (CAPC) at the University of Bristol is a leading centre for primary care research in the UK, one of ten forming the NIHR School for Primary Care Research. It sits within Bristol Medical School, an internationally recognised centre of excellence for population health research and teaching. Follow on Bluesky: @capcbristol.bsky.social, X: @capcbristol and LinkedIn.

About the Gender Violence and Health Centre, London School of Hygiene & Tropical Medicine
The Gender Violence and Health Centre (GVHC) at the London School of Hygiene & Tropical Medicine (LSHTM) is a global leader in research on gender-based violence against women and children. The Centre informs evidence-based prevention strategies, strengthens health systems, and advances policies and interventions to improve safety, health, and well-being of women and children worldwide.

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