Comparing health systems readiness for integrating domestic violence services in Brazil, occupied Palestinian Territories, Nepal and Sri Lanka

Domestic violence (DV) is a global prevalent health problem leading to adverse health consequences, yet health systems are often unprepared to address it. This article presents a comparative synthesis of the health system's pre-conditions necessary to enable integration of DV in health services in Brazil, Nepal, Sri Lanka and occupied Palestinian Territories (oPT). A cross-country, comparative analysis was conducted using a health systems readiness framework. Data collection involved multiple data sources, including qualitative interviews with various stakeholders; focus-group discussions with women; structured facility observations; and a survey with providers. Our findings highlight deficiencies in policy and practice that need to be addressed for an effective DV response. Common readiness gaps include unclear and limited guidance on DV, unsupportive leadership coupled with limited training and resources. Most providers felt unprepared, lacked guidance and felt unsupported and unprotected by managers and their health system. While in Brazil most providers felt they should respond to DV cases, many in Sri Lanka preferred not to. Such organizational and service delivery challenges, in turn, also affected how health providers responded to DV cases leaving them not confident, uncertain about their knowledge and unsure about their role. Furthermore, providers' personal beliefs and values on DV and gender norms also impacted their motivation and ability to respond, prompting some to become 'activists' while others were reluctant to intervene and prone to blame women. Our synthesis also pointed to a gap in women's use of health services for DV as they had low trust in providers. Our conceptual framework demonstrates the importance of having clear policies and highlights the need to engage leadership across every level of the system to reframe challenges and strengthen routine practices. Future research should also determine the ways in which women's understanding and needs related to DV help-seeking are addressed.

Interventions that prevent or respond to intimate partner violence against women and violence against children: a systematic review

Efforts to prevent or respond to intimate partner violence (IPV) and violence against children (VAC) are still disparate worldwide, despite increasing evidence of intersections across these forms of violence. We conducted a systematic review to explore interventions that prevent or respond to IPV and VAC by parents or caregivers, aiming to identify common intervention components and mechanisms that lead to a reduction in IPV and VAC. 30 unique interventions from 16 countries were identified, with 20 targeting both IPV and VAC. Key mechanisms for reducing IPV and VAC in primary prevention interventions included improved communication, conflict resolution, reflection on harmful gender norms, and awareness of the adverse consequences of IPV and VAC on children. Therapeutic programmes for women and children who were exposed to IPV facilitated engagement with IPV-related trauma, increased awareness of the effects of IPV, and promoted avoidance of unhealthy relationships. Evidence gaps in low-income and middle-income countries involved adolescent interventions, post-abuse interventions for women and children, and interventions addressing both prevention and response to IPV and VAC. Our findings strengthen evidence in support of efforts to address IPV and VAC through coordinated prevention and response programmes. However, response interventions for both IPV and VAC are rare and predominantly implemented in high-income countries. Although therapeutic programmes for parents, caregivers, and children in high-income countries are promising, their feasibility in low-income and middle-income countries remains uncertain. Despite this uncertainty, there is potential to improve the use of health services to address IPV and VAC together.

An evidence-based primary health care intervention to address domestic violence against women in Brazil: a mixed method evaluation

BACKGROUND

Health systems have a critical role in a multi-sectoral response to domestic violence against women (DVAW). However, the evidence on interventions is skewed towards high income countries, and evidence based interventions are not easily transferred to low-and middle-income countries (LMIC) where significant social, cultural and economic differences exist. We evaluated feasibility and acceptability of implementation of an intervention (HERA-Healthcare Responding to Violence and Abuse) to improve the response to DVAW in two primary health care clinics (PHC) in Brazil.

METHODS

The study design is a mixed method process and outcome evaluation, based on training attendance records, semi-structured interviews (with 13 Primary Health Care (PHC) providers, two clinic directors and two women who disclosed domestic violence), and identification and referral data from the Brazilian Epidemiological Surveillance System (SINAN).

RESULTS

HERA was feasible and acceptable to women and PHC providers, increased providers' readiness to identify DVAW and diversified referrals outside the health system. The training enhanced the confidence and skills of PHC providers to ask directly about violence and respond to women's disclosures using a women centred, gender and human rights perspective. PHC providers felt safe and supported when dealing with DVAW because HERA emphasised clear roles and collective action within the clinical team. A number of challenges affected implementation including: differential managerial support for the Núcleo de Prevenção da Violência (Violence Prevention Nucleus-NPV) relating to the allocation of resources, monitoring progress and giving feedback; a lack of higher level institutional endorsement prioritising DVAW work; staff turnover; a lack of feedback from external support services to PHC clinics regarding DVAW cases; and inconsistent practices regarding documentation of DVAW.

CONCLUSION

Training should be accompanied by system-wide institutional change including active (as opposed to passive) management support, allocation of resources to support roles within the NPV, locally adapted protocols and guidelines, monitoring progress and feedback. Communication and coordination with external support services and documentation systems are crucial and need improvement. DVAW should be prioritised within leadership and governance structures, for example, by including DVAW work as a specific commissioning goal.

Independent recruitment of different types of phospholipases A2 to the venoms of Caenophidian snakes: the rise of PLA2-IIE within Pseudoboini (Dipsadidae)

Snake venom harbors a wide and diverse array of enzymatic and nonenzymatic toxic components, allowing them to exert myriad effects on their prey. However, they appear to trend toward a few optimal compositional scaffolds, dominated by four major toxin classes: SVMPs, SVSPs, 3FTxs and PLA2s. Nevertheless, the latter appears to be restricted to vipers and elapids, as it has never been reported as a major venom component in rear-fanged species. Here, by investigating the original transcriptomes from 19 species distributed in eight genera from the Pseudoboini tribe (Dipsadidae: Xenodontinae) and screening among seven additional tribes of Dipsadidae and three additional families of advanced snakes, we discovered that a novel type of venom, PLA2, resembling a PLA2-IIE, has been recruited to the venom of some species of the Pseudoboini tribe, where it is a major component. Proteomic and functional analyses of these venoms further indicate that these PLA2s play a relevant role in the venoms from this tribe. Moreover, we reconstructed the phylogeny of PLA2s across different snake groups and show that different types of these toxins have been recruited in at least five independent events in caenophidian snakes. Additionally, we present the first compositional profiling of Pseudoboini venoms. Our results demonstrate how relevant phenotypic traits are convergently recruited by different means and from homologous and nonhomologous genes in phylogenetically and ecologically divergent snake groups, possibly optimizing venom composition to overcome diverse adaptative landscapes.

Improving health system readiness to address violence against women and girls: a conceptual framework

BACKGROUND

There is an increasing focus on readiness of health systems to respond to survivors of violence against women (VAW), a global human rights violation damaging women's health. Health system readiness focuses on how prepared healthcare systems and institutions, including providers and potential users, are to adopt changes brought about by the integration of VAW care into services. In VAW research, such assessment is often limited to individual provider readiness or facility-level factors that need to be strengthened, with less attention to health system dimensions. The paper presents a framework for health system readiness assessment to improve quality of care for intimate partner violence (IPV), which was tested in Brazil and Palestinian territories (oPT).

METHODS

Data synthesis of primary data from 43 qualitative interviews with healthcare providers and health managers in Brazil and oPT to explore readiness in health systems.

RESULTS

The application of the framework showed that it had significant added value in capturing system capabilities - beyond the availability of material and technical capacity - to encompass stakeholder values, confidence, motivation and connection with clients and communities. Our analysis highlighted two missing elements within the initial framework: client and community engagement and gender equality issues. Subsequently, the framework was finalised and organised around three levels of analysis: macro, meso and micro. The micro level highlighted the need to also consider how the system can sustainably involve and interact with clients (women) and communities to ensure and promote readiness for integrating (and participating in) change. Addressing cultural and gender norms around IPV and enhancing support and commitment from health managers was also shown to be necessary for a health system environment that enables the integration of IPV care.

CONCLUSION

The proposed framework helps identify a) system capabilities and pre-conditions for system readiness; b) system changes required for delivering quality care for IPV; and c) connections between and across system levels and capabilities.

Are We Asking Too Much of the Health Sector? Exploring the Readiness of Brazilian Primary Healthcare to Respond to Domestic Violence Against Women

BACKGROUND

There is growing recognition of the health sector's potential role in addressing domestic violence (DV) against women. Although Brazil has a comprehensive policy framework on violence against women (VAW), implementation has been slow and incomplete in primary healthcare (PHC), and little is known about the implementation challenges. This paper aims to assess the readiness of two PHC clinics in urban Brazil to integrate an intervention to strengthen their DV response.

METHODS

We conducted 20 semi-structured interviews with health managers and health providers; a document analysis of VAW and DV policies from São Paulo and Brazil; and 2 structured facility observations. Data were analysed using thematic analysis.

RESULTS

Findings from our readiness assessment revealed gaps in both current policy and practice needing to be addressed, particularly with regards to governance and leadership, health service organisation and health workforce. DV received less political recognition, being perceived as a lower priority compared to other health issues. Lack of clear guidance from the central and municipal levels emerged as a crucial factor that weakened DV policy implementation both by providers and managers. Furthermore, responses to DV lost visibility, as they were diluted within generic violence responses. The organizational structure of the PHC system in São Paulo, which prioritised the number of consultations and household visits as the main performance indicators, was an additional difficulty in legitimising healthcare providers' time to address DV. Individual-level challenges reported by providers included lack of time and knowledge of how to respond, as well as fears of dealing with DV.

CONCLUSION

Assessing readiness is critical because it helps to evaluate what services and infrastructure are already in place, also identifying obstacles that may hinder adaptation and integration of an intervention to strengthen the response to DV before implementation.

Interventions in sexual and reproductive health services addressing violence against women in low-income and middle-income countries: a mixed-methods systematic review

OBJECTIVES

To synthesise evidence on the effectiveness, cost-effectiveness and barriers to responding to violence against women (VAW) in sexual and reproductive health (SRH) services in low/middle-income countries (LMICs).

DESIGN

Mixed-methods systematic review.

DATA SOURCES

Medline, Embase, Psycinfo, Cochrane, Cinahl, IMEMR, Web of Science, Popline, Lilacs, WHO RHL, ClinicalTrials.gov, Google, Google Scholar, websites of key organisations through December 2019.

ELIGIBILITY CRITERIA

Studies of any design that evaluated VAW interventions in SRH services in LMICs.

DATA EXTRACTION AND SYNTHESIS

Concurrent narrative quantitative and thematic qualitative syntheses, integration through line of argument and mapping onto a logic model. Two reviewers extracted data and appraised quality.

RESULTS

26 studies of varied interventions using heterogeneous outcomes. Of ten interventions that strengthened health systems capacity to respond to VAW during routine SRH consultation, three reported no harm and reduction in some types of violence. Of nine interventions that strengthened health systems and communities' capacity to respond to VAW, three reported conflicting effects on re-exposure to some types of VAW and mixed effect on SRH. The interventions increased identification of VAW but had no effect on the provision (75%-100%) and uptake (0.6%-53%) of referrals to VAW services. Of seven psychosocial interventions in addition to SRH consultation that strengthened women's readiness to address VAW, four reduced re-exposure to some types of VAW and improved health. Factors that disrupted the pathway to better outcomes included accepting attitudes towards VAW, fear of consequences and limited readiness of the society, health systems and individuals. No study evaluated cost-effectiveness.

CONCLUSIONS

Some VAW interventions in SRH services reduced re-exposure to some types of VAW and improved some health outcomes in single studies. Future interventions should strengthen capacity to address VAW across health systems, communities and individual women. First-line support should be better tailored to women's needs and expectations.

PROSPERO REGISTRATION NUMBER

CRD42019137167.

Supporting children and adolescents who have experienced sexual abuse to access services: Community health workers' experiences in Kenya

Child sexual abuse (CSA) is a global health problem with significant health consequences. The World Health Organization recommends immediate and long-term treatment for all survivors. However, in low- and middle-income countries, less than 10 % of sexually abused children seek health services. Community health workers (CHWs) can potentially increase uptake of services, but, the risks and benefits of services provided by CHWs are poorly understood.

METHODS

Through in-depth interviews, we examined the experiences of CHWs providing services to children in Kenya. Sixteen CHWs were purposively selected from two locations. Data were audio-recorded, transcribed verbatim and analysed thematically.

FINDINGS

Nearly all the CHWs reported assisting children who had experienced sexual abuse. Children were brought to their attention by caregivers, neighbours, teachers, local authorities or the police. CHWs roles included providing information and advice, assisting the child to report to the police, access healthcare or find shelter. Multiple challenges were reported including lack of support from formal institutions; community norms; safety concerns; inadequate resources and interference from family, perpetrators and local authorities. Lack of protocols and training on how to handle children was evident.

CONCLUSIONS

CHWs are a crucial community-level resource for CSA survivors and their caregivers. However, community norms, lack of guidelines and training may compromise the quality of services provided. There is a significant gap in literature on service models for CHWs delivering CSA services. Data are lacking on what services CHWs can effectively offer, how they should be delivered and what factors may influence delivery, acceptance and uptake of services.

Exploring the feasibility and acceptability of integrating screening for gender-based violence into HIV counselling and testing for adolescent girls and young women in Tanzania and South Africa

BACKGROUND

Gender-based violence (GBV) undermines HIV prevention and treatment cascades, particularly among women who report partner violence. Screening for violence during HIV testing, and prior to offering pre-exposure prophylaxis (PrEP) to HIV uninfected women, provides an opportunity to identify those at heightened HIV risk and greater potential for non-adherence or early discontinuation of PrEP. The paper describes our experience with offering integrated GBV screening and referral as part of HIV counselling and testing. This component was implemented within EMPOWER, a demonstration project offering combination HIV prevention, including daily oral PrEP, to young women in South Africa and Tanzania.

METHODS

Between February 2017 and March 2018, a process evaluation was conducted to explore views, experiences and practices of stakeholders (study participants and study clinical staff) during implementation of the GBV screening component. This article assesses the feasibility and acceptability of the approach from multiple stakeholder perspectives, drawing on counselling session observations (n = 10), in-depth interviews with participants aged 16-24 (n = 39) and clinical staff (n = 13), and notes from debriefings with counsellors. Study process data were also collected (e.g. number of women screened and referred). Following a thematic inductive approach, qualitative data were analysed using qualitative software (NVivo 11).

RESULTS

Findings show that 31% of young women screened positive for GBV and only 10% requested referrals. Overall, study participants accessing PrEP were amenable to being asked about violence during HIV risk assessment, as this offered the opportunity to find emotional relief and seek help, although a few found this traumatic. In both sites, the sensitive and empathetic approach of the staff helped mitigate distress of GBV disclosure. In general, the delivery of GBV screening in HCT proved to be feasible, provided that the basic principles of confidentiality, staff empathy, and absence of judgment were observed. However, uptake of linkage to further care remained low in both sites.

CONCLUSION

Most stakeholders found GBV screening acceptable and feasible. Key principles that should be in place for young women to be asked safely about GBV during HIV counselling and testing included respect for confidentiality, a youth-friendly and non-judgmental environment, and a functioning referral network.

Disclosure of PrEP use by young women in South Africa and Tanzania: qualitative findings from a demonstration project

Investigating how young women disclose oral pre-exposure prophylaxis (PrEP) use is important given evidence that disclosure is associated with higher adherence. We report qualitative results on PrEP disclosure among young women in South Africa and Tanzania who participated in a PrEP demonstration project (EMPOWER). In total, 81 in-depth interviews were conducted with 39 young women aged 16-24 years-25 from Johannesburg and 14 from Mwanza-at approximately 3, 6 and/or 9 months post-enrolment. Analysis of data was thematic and inductive. Most Johannesburg participants were students in the inner-city; in Mwanza, all worked in recreational venues, occasionally engaging in sexual transactions with customers. A continuum of approaches was evident. Partner disclosure was common in Johannesburg but less so in Mwanza, where many partners were feared as judgemental and potentially violent. In both sites, participants commonly disclosed to family to secure support, and to friends and work colleagues to advocate about PrEP and encourage uptake among at-risk peers. Adherence clubs appeared helpful in building participants' skills and confidence to disclose, particularly in gender-inequitable sexual relationships. PrEP counselling for young women should focus on strengthening communication skills and helping develop strategies for safe disclosure.

Adaptive work in the primary health care response to domestic violence in occupied Palestinian territory: a qualitative evaluation using Extended Normalisation Process Theory

BACKGROUND

A health system response to domestic violence against women is a global priority. However, little is known about how these health system interventions work in low-and-middle-income countries where there are greater structural barriers. Studies have failed to explore how context-intervention interactions affect implementation processes. Healthcare Responding to Violence and Abuse aimed to strengthen the primary healthcare response to domestic violence in occupied Palestinian territory. We explored the adaptive work that participants engaged in to negotiate contextual constraints.

METHODS

The qualitative study involved 18 participants at two primary health care clinics and included five women patients, seven primary health care providers, two clinic case managers, two Ministry of Health based gender-based violence focal points and two domestic violence trainers. Semi-structured interviews were used to elicit participants' experiences of engaging with HERA, challenges encountered and how these were negotiated. Data were analysed using thematic analysis drawing on Extended Normalisation Process Theory. We collected clinic data on identification and referral of domestic violence cases and training attendance.

RESULTS

HERA interacted with political, sociocultural and economic aspects of the context in Palestine. The political occupation restricted women's movement and access to support services, whilst the concomitant lack of police protection left providers and women feeling exposed to acts of family retaliation. This was interwoven with cultural values that influenced participants' choices as they negotiated normative structures that reinforce violence against women. Participants engaged in adaptive work to negotiate these challenges and ensure that implementation was safe and workable. Narratives highlight the use of subterfuge, hidden forms of agency, governing behaviours, controls over knowledge and discretionary actions. The care pathway did not work as anticipated, as most women chose not to access external support. An emergent feature of the intervention was the ability of the clinic case managers to improvise their role.

CONCLUSIONS

Flexible use of ENPT helped to surface practices the providers and women patients engaged in to make HERA workable. The findings have implications for the transferability of evidenced based interventions on health system response to violence against women in diverse contexts, and how HERA can be sustained in the long-term.

Exploring health system readiness for adopting interventions to address intimate partner violence: a case study from the occupied Palestinian Territory

Domestic violence (DV) against women is a widespread violation of human rights. Adoption of effective interventions to address DV by health systems may fail if there is no readiness among organizations, institutions, providers and communities. There is, however, a research gap in our understanding of health systems' readiness to respond to DV. This article describes the use of a health system's readiness assessment to identify system obstacles to enable successful implementation of a primary health-care (PHC) intervention to address DV in the occupied Palestinian Territory (oPT). This article describes a case study where qualitative methods were used, namely 23 interviews with PHC providers and key informants, one stakeholder meeting with 19 stakeholders, two health facility observations and a document review of legal and policy materials on DV in oPT. We present data on seven dimensions of health systems. Our findings highlight the partial readiness of health systems and services to adopt a new DV intervention. Gaps were identified in: governance (no DV legislation), financial resources (no public funding and limited staff and infrastructure) and information systems (no uniform system), co-ordination (disjointed referral network) and to some extent around the values system (tension between patriarchal views on DV and more gender equal norms). Additional service-level barriers included unclear leadership structure at district level, uncertain roles for front-line staff, limited staff protection and the lack of a private space for identification and counselling. Findings also pointed to concrete actions in each system dimension that were important for effective delivery. This is the first study to use an adapted framework to assess health system readiness (HSR) for implementing an intervention to address DV in low- and middle-income countries. More research is needed on HSR to inform effective implementation and scale up of health-care-based DV interventions.

Barriers to women's disclosure of domestic violence in health services in Palestine: qualitative interview-based study

Background

Domestic violence (DV) damages health and requires a global public health response and engagement of clinical services. Recent surveys show that 27% of married Palestinian women experienced some form of violence from their husbands over a 12 months' period, but only 5% had sought formal help, and rarely from health services. Across the globe, barriers to disclosure of DV have been recorded, including self-blame, fear of the consequences and lack of knowledge of services. This is the first qualitative study to address barriers to disclosure within health services for Palestinian women.

Methods

In-depth interviews were carried out with 20 women who had experienced DV. They were recruited from a non-governmental organisation offering social and legal support. Interviews were recorded, transcribed and translated into English and the data were analysed thematically.

Results

Women encountered barriers at individual, health care service and societal levels. Lack of knowledge of available services, concern about the health care primary focus on physical issues, lack of privacy in health consultations, lack of trust in confidentiality, fear of being labelled ‘mentally ill’ and losing access to their children were all highlighted. Women wished for health professionals to take the initiative in enquiring about DV. Wider issues concerned women’s social and economic dependency on their husbands which led to fears about transgressing social and cultural norms by speaking out. Women feared being blamed and ostracised by family members and others, or experiencing an escalation of violence.

Conclusions

Palestinian women’s agency to be proactive in help-seeking for DV is clearly limited. Our findings can inform training of health professionals in Palestine to address these barriers, to increase awareness of the link between DV and many common presentations such as depression, to ask sensitively about DV in private, reassure women about confidentiality, and increase awareness among women of the role that health services can play in DV.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-09907-8.

Health systems software factors and their effect on the integration of sexual and reproductive health and HIV services

Despite a large and growing body of literature on sexual and reproductive health (SRH) and HIV integration, the drivers of integration of SRH and HIV services, from a health systems perspective, are not well understood. These drivers include complex so-called hardware (structural and resource) and software (values and norms, and human relations and interactions) factors. Two groups of software factors emerge as essential enablers of effective integration of SRH and HIV services that often interact with systems hardware: (1) leadership, management, and governance processes and (2) provider motivation, agency, and relationships. Evidence suggests the potential for software elements that are essential enablers to overcome some of the obstacles posed by the non-integration of health system hardware elements (eg, financing, guidelines, and commodity supplies). These enabling factors include flexible decision making, inclusive management, and support in motivating frontline staff who can work with agency as a team. Improved software, even within constrained hardware (especially in low-income and middle-income countries), can directly contribute to improved SRH and HIV service delivery.

Exploring health systems readiness for domestic violence in Brazil and Palestine

Background

Increasing attention has been paid on health systems readiness around domestic violence (DV), a global health issue leading to adverse health consequences. This article aims to present a comparative synthesis of the health system pre-conditions necessary to enable integration of services for domestic violence in Brazil and Palestine.

Methods

A health systems readiness assessment was conducted to explore health systems gaps. Multiple, data sources were used, ranging from qualitative interviews with various stakeholders (e.g. providers, health managers and key informants); structured facility observations (8 clinics); policy document reviews.

Results

Our findings highlight deficiencies in policy and practice that need to be addressed for an effective response. Common preparedness gaps include unclear governance and unsupportive leadership structure; challenges around service delivery such as limited staff protection and limited coordination; and untrained health workforce. Our results illustrate the importance of having clear guidance on roles and responsibilities for both health managers and clinicians. In Brazil, although there is a legal and regulatory system on domestic violence, its implementation has been patchy as health regulations are not well-defined. In both settings, the limited higher-level commitment and political will to reduce violence has affected implementation. Limited guidance, coupled with limited training and perceived lack of support in the facility environment, also impacted on providers' knowledge and confidence in responding to violence. Fear of family retaliation affected frontline providers' actions in both countries.

Conclusions

Our innovative framework helped identify anticipated readiness gaps. It has shown the importance of nurturing the role and values of managers and engaging the leadership across every system to reframe challenges, and strengthening routine practices to encourage staff engagement in responding to DV.

Key messages

Conducting a health systems readiness assessment before integrating a new service can anticipate preparedness gaps and inform adaptation that will enhance service uptake and effectiveness. Critical systems gaps to address before integrating domestic violence services in healthcare include staff and managers’ values, leadership and organisational support to frontline providers.

The implementation and effectiveness of the one stop centre model for intimate partner and sexual violence in low- and middle-income countries: a systematic review of barriers and enablers

Introduction

Many low- and middle-income countries have implemented health-system based one stop centres to respond to intimate partner violence (IPV) and sexual violence. Despite its growing popularity in low- and middle-income countries and among donors, no studies have systematically reviewed the one stop centre. Using a thematic synthesis approach, this systematic review aims to identify enablers and barriers to implementation of the one stop centre (OSC) model and to achieving its intended results for women survivors of violence in low- and middle-income countries.

Methods

We searched PubMed, CINAHL and Embase databases and grey literature using a predetermined search strategy to identify all relevant qualitative, quantitative and mixed methods studies. Overall, 42 studies were included from 24 low- and middle-income countries. We used a three-stage thematic synthesis methodology to synthesise the qualitative evidence, and we used the CERQual (Confidence in the Evidence from Reviews of Qualitative Research) approach to assess confidence in the qualitative research. Meta-analysis could not be performed due heterogeneity in results and outcome measures. Quantitative data are presented by individual study characteristics and outcomes, and key findings are incorporated into the qualitative thematic framework.

Results

The review found 15 barriers with high-confidence evidence and identified seven enablers with moderate-confidence evidence. These include barriers to implementation such as lack of multisectoral staff and private consultation space as well as barriers to achieving the intended result of multisectoral coordination due to fragmented services and unclear responsibilities of implementing partners. There were also differences between enablers and barriers of various OSC models such as the hospital-based OSC, the stand-alone OSC and the NGO-run OSC.

Conclusion

This review demonstrates that there are several barriers that have often prevented the OSC model from being implemented as designed and achieving the intended result of providing high quality, accessible, acceptable, multisectoral care. Existing OSCs will likely require strategic investment to address these specific barriers before they can achieve their ultimate goal of reducing survivor retraumatisation when seeking care. More rigorous and systematic evaluation of the OSC model is needed to better understand whether the OSC model of care is improving support for survivors of IPV and sexual violence.

The systematic review protocol was registered and is available online (PROSPERO: CRD42018083988).

Using Digital Technology for Sexual and Reproductive Health: Are Programs Adequately Considering Risk?

Digital technologies provide opportunities for advancing sexual and reproductive health and services but also present potential risks. We propose 4 steps to reducing potential harms: (1) consider potential harms during intervention design, (2) mitigate or minimize potential harms during the design phase, (3) measure adverse outcomes during implementation, and (4) plan how to support those reporting adverse outcomes.

A new approach to assess the capability of health facilities to provide clinical care for sexual violence against women: a pilot study

Several tools have been developed to collect information on health facility preparedness to provide sexual violence response services; however, little guidance exists on how this information can be used to better understand which functions a facility can perform. Our study therefore aims to propose a set of signal functions that provide a framework for monitoring the availability of clinical sexual violence services. To illustrate the potential insights that can be gained from using our proposed signal functions, we used the framework to analyse data from a health facility census conducted in Central Province, Zambia. We collected the geographic coordinates of health facilities and police stations to assess women's proximity to multi-sectoral sexual violence response services. We defined three key domains of clinical sexual violence response services, based on the timing of the visit to the health facility in relation to the most recent sexual assault: (1) core services, (2) immediate care, and (3) delayed and follow-up care. Combining information from all three domains, we estimate that just 3% of facilities were able to provide a comprehensive response to sexual violence, and only 16% could provide time-sensitive immediate care services such as HIV post-exposure prophylaxis and emergency contraception. Services were concentrated in hospitals, with few health centres and no health posts fulfilling the signal functions for any of the three domains. Only 23% of women lived within 15 km of comprehensive clinical sexual violence health services, and 38% lived within 15 km of immediate care. These findings point to a need to develop clear strategies for decentralizing sexual violence services to maximize coverage and ensure equity in access. Overall, our findings suggest that our proposed signal functions could be a simple and valuable approach for assessing the availability of clinical sexual violence response services, identifying areas for improvement and tracking improvements over time.

Unintended Consequences of mHealth Interactive Voice Messages Promoting Contraceptive Use After Menstrual Regulation in Bangladesh: Intimate Partner Violence Results From a Randomized Controlled Trial

BACKGROUND

Mobile phones for health (mHealth) hold promise for delivering behavioral interventions. We evaluated the effect of automated interactive voice messages promoting contraceptive use with a focus on long-acting reversible contraceptives (LARCs) among women in Bangladesh who had undergone menstrual regulation (MR), a procedure to "regulate the menstrual cycle when menstruation is absent for a short duration."

METHODS

We recruited MR clients from 41 public- and private-sector clinics immediately after MR. Eligibility criteria included having a personal mobile phone and consenting to receive messages about family planning by phone. We randomized participants remotely to an intervention group that received at least 11 voice messages about contraception over 4 months or to a control group (no messages). The primary outcome was LARC use at 4 months. Adverse events measured included experience of intimate partner violence (IPV). Researchers recruiting participants and 1 analyst were blinded to allocation groups. All analyses were intention to treat. The trial is registered with ClinicalTrials.gov (NCT02579785).

RESULTS

Between December 2015 and March 2016, 485 women were allocated to the intervention group and 484 to the control group. We completed follow-up on 389 intervention and 383 control participants. Forty-eight (12%) participants in the intervention group and 59 (15%) in the control group reported using a LARC method at 4 months (adjusted odds ratio [aOR] using multiple imputation=0.95; 95% confidence interval [CI]=0.49 to 1.83; P=.22). Reported physical IPV was higher in the intervention group: 42 (11%) intervention versus 25 (7%) control (aOR=1.97; 95% CI=1.12 to 3.46; P=.03) when measured using a closed question naming acts of violence. No violence was reported in response to an open question about effects of being in the study.

CONCLUSIONS

The intervention did not increase LARC use but had an unintended consequence of increasing self-reported IPV. Researchers and health program designers should consider possible negative impacts when designing and evaluating mHealth and other reproductive health interventions. IPV must be measured using closed questions naming acts of violence.

Children's and caregivers' perspectives about mandatory reporting of child maltreatment: a meta-synthesis of qualitative studies

OBJECTIVE

To systematically synthesise qualitative research that explores children's and caregivers' perceptions of mandatory reporting.

DESIGN

We conducted a meta-synthesis of qualitative studies.

DATA SOURCES

Searches were conducted in Medline, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Criminal Justice Abstracts, Education Resources Information Center, Sociological Abstracts and Cochrane Libraries.

ELIGIBILITY CRITERIA

English-language, primary, qualitative studies that investigated children's or caregivers' perceptions of reporting child maltreatment were included. All healthcare and social service settings implicated by mandatory reporting laws were included.

DATA EXTRACTION AND SYNTHESIS

Critical appraisal of included studies involved a modified checklist from the Critical Appraisal Skills Programme (CASP). Two independent reviewers extracted data, including direct quotations from children and caregivers (first-order constructs) and interpretations by study authors (second-order constructs). Third-order constructs (the findings of this meta-synthesis) involved synthesising second-order constructs that addressed strategies to improve the mandatory reporting processes for children or caregivers-especially when these themes addressed concerns raised by children or caregivers in relation to the reporting process.

RESULTS

Over 7935 citations were retrieved and 35 articles were included in this meta-synthesis. The studies represent the views of 821 caregivers, 50 adults with histories of child maltreatment and 28 children. Findings suggest that children and caregivers fear being reported, as well as the responses to reports. Children and caregivers identified a need for improvement in communication from healthcare providers about mandatory reporting, offering preliminary insight into child-driven and caregiver-driven strategies to mitigate potential harms associated with reporting processes.

CONCLUSION

Research on strategies to mitigate potential harms linked to mandatory reporting is urgently needed, as is research that explores children's experiences with this process.

Men's use of sexual health and HIV services in Swaziland: a mixed methods study

BACKGROUND

Over one-quarter of the adult population in Swaziland is estimated to be HIV positive. Men's use of sexual health (SH) services has significant implications for HIV prevention. This study aimed to understand Swazi men's health-seeking behaviours in relation to SH and HIV services.

METHODS

A household survey was conducted in Manzini (n=503), complemented by 23 semi-structured interviews and two focus group discussions (with a total of 10 participants).

RESULTS

One-third of male survey participants used SH services in the past year, most commonly HIV testing (28%). Service users were more likely to be sexually active (aOR 3.21, 95% CI: 1.81-5.68 for those with one partner; and aOR 2.35, 95% CI: 1.25-4.41 for those with multiple partners) compared with service non-users. Service users were less likely to prefer HIV services to be separated from other healthcare services (aOR 0.50, 95% CI: 0.35-0.71), or to agree with travelling further for their HIV test (aOR 0.52, 95% CI: 0.33-0.82) compared with non-users, after controlling for age-group and education. Men avoided SH services because they feared being stigmatised by STI/HIV testing, are uncomfortable disclosing SH problems to female healthcare providers, and avoided HIV testing by relying on their wife's results as a proxy for their own status. Informal providers, such as traditional healers, were often preferred because practitioners were more often male, physical exams were not required and appointments and payment options were flexible.

CONCLUSION

To improve men's uptake of SH services, providers and services need to be more sensitive to men's privacy concerns, time restrictions and the potential stigma associated with STI/HIV testing.

Missed treatment opportunities and barriers to comprehensive treatment for sexual violence survivors in Kenya: a mixed methods study

Background

In Kenya, most sexual violence survivors either do not access healthcare, access healthcare late or do not complete treatment. To design interventions that ensure optimal healthcare for survivors, it is important to understand the characteristics of those who do and do not access healthcare. In this paper, we aim to: compare the characteristics of survivors who present for healthcare to those of survivors reporting violence on national surveys; understand the healthcare services provided to survivors; and, identify barriers to treatment.

Methods

A mixed methods approach was used. Hospital records for survivors from two referral hospitals were compared with national-level data from the Kenya Demographic and Health Survey 2014, and the Violence Against Children Survey 2010. Descriptive summaries were calculated and differences in characteristics of the survivors assessed using chi-square tests. Qualitative data from six in-depth interviews with healthcare providers were analysed thematically.

Results

Among the 543 hospital respondents, 93.2% were female; 69.5% single; 71.9% knew the perpetrator; and 69.2% were children below 18 years. Compared to respondents disclosing sexual violence in nationally representative datasets, those who presented at hospital were less likely to be partnered, male, or assaulted by an intimate partner. Data suggest missed opportunities for treatment among those who did present to hospital: HIV PEP and other STI prophylaxis was not given to 30 and 16% of survivors respectively; 43% of eligible women did not receive emergency contraceptive; and, laboratory results were missing in more than 40% of the records. Those aged 18 years or below and those assaulted by known perpetrators were more likely to miss being put on HIV PEP. Qualitative data highlighted challenges in accessing and providing healthcare that included stigma, lack of staff training, missing equipment and poor coordination of services.

Conclusions

Nationally, survivors at higher risk of not accessing healthcare include older survivors; partnered or ever partnered survivors; survivors experiencing sexual violence from intimate partners; children experiencing violence in schools; and men. Interventions at the community level should target survivors who are unlikely to access healthcare and address barriers to early access to care. Staff training and specific clinical guidelines/protocols for treating children are urgently needed.

Factors shaping political priorities for violence against women-mitigation policies in Sri Lanka

Background

Although violence against women (VAW) is a global public health issue, its importance as a health issue is often unrecognized in legal and health policy documents. This paper uses Sri Lanka as a case study to explore the factors influencing the national policy response to VAW, particularly by the health sector.

Methods

A document based health policy analysis was conducted to examine current policy responses to VAW in Sri Lanka using the Shiffman and Smith (2007) policy analysis framework.

Results

The findings suggest that the networks and influences of various actors in Sri Lanka, and their ideas used to frame the issue of VAW, have been particularly important in shaping the nature of the policy response to date. The Ministry of Women and Child Affairs led the national response on VAW, but suffered from limited financial and political support. Results also suggest that there was low engagement by the health sector in the initial policy response to VAW in Sri Lanka, which focused primarily on criminal legislation, following global influences. Furthermore, a lack of empirical data on VAW has impeded its promotion as a health policy issue, despite financial support from international organisations enabling an initial health systems response by the Ministry of Health. Until a legal framework was established (2005), the political context provided limited opportunities for VAW to also be construed as a health issue. It was only then that the Ministry of Health got legitimacy to institutionalise VAW services.

Conclusion

Nearly a decade later, a change in government has led to a new national plan on VAW, giving a clear role to the health sector in the fight against VAW. High-level political will, criminalisation of violence, coalesced women’s groups advocating for legislative change, prevalence data, and financial support from influential institutions are all critical elements helping frame violence as a national public health issue.

Well being in patients on CAPD and hemodialysis

In the present multicenter study, 120 pts who had been treated by both hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) for at least 6 months each, were invited to answer questions on 34 matters, to compare symptoms and their well-being while on the two treatments. Patients were invited to choose HD or CAPD and indicate the reasons for their choice. For 28 patients the first treatment was HD and for 92 CAPD. The mean time between the change of therapy and the study was 46±35 months. Their final choices were found to be strictly related to the present treatment (p<0.001). The reasons for choice of CAPD were: more free time (21%), more freedom (67%), better well being (44%), less worry (5%); for HD they were: more free time (53%), better well-being (39%), less worry (13%), no need for a peritoneal catheter and fewer clinical complications (19%). The catheter was considered more cumbersome than the A.V. fistula, the time involved was considered to be shorter on HD by 52 patients and on CAPD by 39, thirst and cramps were considered to be more frequent and severe on CAPD by half of the patients. The prevalence and severity of problems and symptoms and choice of treatment were not related to sex, job, education or age.

Numbers, systems, people: how interactions influence integration. Insights from case studies of HIV and reproductive health services delivery in Kenya

Drawing on rich data from the Integra evaluation of integrated HIV and reproductive-health services, we explored the interaction of systems hardware and software factors to explain why some facilities were able to implement and sustain integrated service delivery while others were not. This article draws on detailed mixed-methods data for four case-study facilities offering reproductive-health and HIV services between 2009 and 2013 in Kenya: (i) time-series client flow, tracking service uptake for 8841 clients; (ii) structured questionnaires with 24 providers; (iii) in-depth interviews with 17 providers; (iv) workload and facility data using a periodic activity review and cost-instruments; and (v) contextual data on external activities related to integration in study sites. Overall, our findings suggested that although structural factors like stock-outs, distribution of staffing and workload, rotation of staff can affect how integrated care is provided, all these factors can be influenced by staff themselves: both frontline and management. Facilities where staff displayed agency of decision making, worked as a team to share workload and had management that supported this, showed better integration delivery and staff were able to overcome some structural deficiencies to enable integrated care. Poor-performing facilities had good structural integration, but staff were unable to utilize this because they were poorly organized, unsupported or teams were dysfunctional. Conscientious objection and moralistic attitudes were also barriers.Integra has demonstrated that structural integration is not sufficient for integrated service delivery. Rather, our case studies show that in some cases excellent leadership and peer-teamwork enabled facilities to perform well despite resource shortages. The ability to provide support for staff to work flexibly to deliver integrated services and build resilient health systems to meet changing needs is particularly relevant as health systems face challenges of changing burdens of disease, climate change, epidemic outbreaks and more.

Mandated reporters' experiences with reporting child maltreatment: a meta-synthesis of qualitative studies

OBJECTIVE

To systematically search for research about the effectiveness of mandatory reporting of child maltreatment and to synthesise qualitative research that explores mandated reporters' (MRs) experiences with reporting.

DESIGN

As no studies assessing the effectiveness of mandatory reporting were retrieved from our systematic search, we conducted a meta-synthesis of retrieved qualitative research. Searches in Medline (Ovid), Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Sociological Abstracts, Education Resources Information Center, Criminal Justice Abstracts and Cochrane Library yielded over 6000 citations, which were deduplicated and then screened by two independent reviewers. English-language, primary qualitative studies that investigated MRs' experiences with reporting of child maltreatment were included. Critical appraisal involved a modified checklist from the Critical Appraisal Skills Programme and qualitative meta-synthesis was used to combine results from the primary studies.

SETTING

All healthcare and social-service settings implicated by mandatory reporting laws were included. Included studies crossed nine high-income countries (USA, Australia, Sweden, Taiwan, Canada, Norway, Finland, Israel and Cyprus) and three middle-income countries (South Africa, Brazil and El Salvador).

PARTICIPANTS

The studies represent the views of 1088 MRs.

OUTCOMES

Factors that influence MRs' decision to report and MRs' views towards and experiences with mandatory reporting of child maltreatment.

RESULTS

Forty-four articles reporting 42 studies were included. Findings indicate that MRs struggle to identify and respond to less overt forms of child maltreatment. While some articles (14%) described positive experiences MRs had with the reporting process, negative experiences were reported in 73% of articles and included accounts of harm to therapeutic relationships and child death following removal from their family of origin.

CONCLUSIONS

The findings of this meta-synthesis suggest that there are many potentially harmful experiences associated with mandatory reporting and that research on the effectiveness of this process is urgently needed.

Should community health workers offer support healthcare services to survivors of sexual violence? a systematic review

Background

Sexual violence is widespread, yet relatively few survivors receive healthcare or complete treatment. In low and middle-income countries, community health workers (CHWs) have the potential to provide support services to large numbers of survivors. The aim of this review was to document the role of CHWs in sexual violence services. We aimed to: 1) describe existing models of CHWs services including characteristics of CHWs, services delivered and populations served; 2) explore acceptability of CHWs’ services to survivors and feasibility of delivering such services; and 3) document the benefits and challenges of CHW-provided sexual violence services.

Methods

Quantitative and qualitative studies reporting on CHWs and other community-level paraprofessional volunteer services for sexual violence were eligible for inclusion. CHWs and sexual violence were defined according to WHO criteria. The review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Quality of included studies was assessed using two quality assessment tools for quantitative, and, the methodology checklist by the National Institute for Health and Clinical Excellence for qualitative studies. Data were extracted and analysed separately for quantitative and qualitative studies and results integrated using a framework approach.

Results

Seven studies conducted in six countries (Democratic Republic of Congo, Rwanda, Burma, United States of America, Scotland, Israel) met the inclusion criteria. Different models of care had diverse CHWs roles including awareness creation, identifying, educating and building relationships with survivors, psychosocial support and follow up. Although sociocultural factors may influence CHWs’ performance and willingness of survivors to use their services, studies often did not report on CHWs characteristics. Few studies assessed acceptability of CHWs’ to survivors or feasibility of delivery of services. However, participants mentioned a range of benefits including decreased incidence of violence, CHWs being trusted, approachable, non-judgmental and compassionate. Challenges identified were high workload, confidentiality issues and community norms influencing performance.

Conclusions

There is a dearth of research on CHWs services for sexual violence. Findings suggest that involving CHWs may be beneficial, but potential challenges and harms related to CHW-provided services exist. No different models of CHW-provided care have been robustly evaluated for effects on patient outcomes. Further research to establish survivors’ views on these services, and, their effectiveness is desperately needed.

Electronic supplementary material

The online version of this article (10.1186/s12914-017-0137-z) contains supplementary material, which is available to authorized users.

Healthcare system responses to intimate partner violence in low and middle-income countries: evidence is growing and the challenges become clearer

The damage to health caused by intimate partner violence demands effective responses from healthcare providers and healthcare systems worldwide. To date, most evidence for the few existing, effective interventions in use comes from high-income countries. Gupta et al. provide rare evidence of a nurse-delivered intimate partner violence screening, supportive care and referral intervention from a large-scale randomised trial in Mexican public health clinics. No difference was found in the primary outcome of reduction in intimate partner violence. There were significant short-term benefits in safety planning and mental health (secondary outcomes) for women in the intervention arm, but these were not sustained.This important study highlights the challenges of primary outcome choices in such studies, and further challenges for the sustainability of healthcare systems and healthcare provider interventions. These challenges include the role of theory for sustainability and the risk that baseline measures of intimate partner violence can wash out intervention effects. We emphasise the importance of studying the processes of adaptation, integration and coordination in the context of the wider healthcare system.Please see related article: https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-017-0880-y.

Fertility intentions and contraceptive practices among clinic-users living with HIV in Kenya: a mixed methods study

BACKGROUND

Preventing unwanted pregnancies in Women Living with HIV (WLHIV) is a recognised HIV-prevention strategy. This study explores the fertility intentions and contraceptive practices of WLHIV using services in Kenya.

METHODS

Two hundred forty women self-identifying as WLHIV who attended reproductive health services in Kenya were interviewed with a structured questionnaire in 2011; 48 were also interviewed in-depth. STATA SE/13.1, Nvivo 8 and thematic analysis were used.

RESULTS

Seventy one percent participants did not want another child; this was associated with having at least two living children and being the bread-winner. FP use was high (92%) but so were unintended pregnancies (40%) while living with HIV. 56 women reported becoming pregnant "while using FP": all were using condoms or short-term methods. Only 16% participants used effective long-acting reversible contraceptives or permanent methods (LARC-PM). Being older than 25 years and separated, widowed or divorced were significant predictors of long-term method use. Qualitative data revealed strong motivation among WLHIV to plan or prevent pregnancies to avoid negative health consequences. Few participants received good information about contraceptive choices.

CONCLUSIONS

WLHIV need better access to FP advice and a wider range of contraceptives including LARC to enable informed choices that will protect their fertility intentions, ensure planned pregnancies and promote safe child-bearing.

TRIAL REGISTRATION

Integra is a non-randomised pre-post intervention trial registered with Current Controlled Trials ID: NCT01694862 .

Barriers and Facilitators to Integrating Health Service Responses to Intimate Partner Violence in Low- and Middle-Income Countries: A Comparative Health Systems and Service Analysis

This systematic review synthesizes 11 studies of health‐sector responses to intimate partner violence (IPV) in low‐ and middle‐income countries. The services that were most comprehensive and integrated in their responsiveness to IPV were primarily in primary health and antenatal care settings. Findings suggest that the following facilitators are important: availability of clear guidelines, policies, or protocols; management support; intersectoral coordination with clear, accessible on‐site and off‐site referral options; adequate and trained staff with accepting and empathetic attitudes toward survivors of IPV; initial and ongoing training for health workers; and a supportive and supervised environment in which to enact new IPV protocols. A key characteristic of the most integrated responses was the connection or “linkages” between different individual factors. Irrespective of their service entry point, what emerged as crucial was a connected systems‐level response, with all elements implemented in a coordinated manner.

Perceptions and Experiences of Integrated Service Delivery Among Women Living with HIV Attending Reproductive Health Services in Kenya: A Mixed Methods Study

This is one of the few studies that explores preferences of and experiences with integrated sexual and reproductive health (SRH)-HIV care among users of mainstream family planning and postnatal care services who are women living with HIV (WLWH). This paper reports on the quantitative data from 179 clients attending public sector clinics and from 30 qualitative in-depth interviews with WLHIV in Kenya. Quantitative data show that integration is happening for the vast majority of these clients at their last HIV visit. However, qualitative data show that very often the care received by WLWH is fragmented as providers do not offer multiple same-day appointments for FP and ARV refills. Our study has shown factors that could either prevent or enable receipt of integrated SRH and HIV care for WLWH. To address these factors, management systems need to be able to support providers to make flexible decisions and facilitate better coordination and communication across clinics within facilities.

Gender-based and Sexual Violence against Women during Armed Conflict

Sexual and gender-based violence in armed conflicts lacks visibility and is not fully understood as it is often labelled as a woman's-only issue. Its gendered nature extends beyond the actual period ofconflict, into the period of rehabilitation and reconstruc tion, carrying with it many physical and psychological problems. The sufference endured by women both during the following the conflict is strictly related to the rooted structural gender inequalities within societies in general. In situations of conflict women's oppression and abuse further increase their usual subordination. For example, traditional barriers to health care, including the lack of diagnostic equipment and adequate treatment; the insufficiency of premises for the treatment of survivors; the lack of dedicated venues to seek assistance; poor supplies of essential and specific drugs, together with an inadequacy of health personnel, become even more problematic, and all contribute to poor primary health care.

Therefore, understanding the roots of unequal gender treatment, and thus the cultural setting of a community; becomes essential when dealing with the phenomenon of sexual violence. In particular, multidimensional and gender-sensitive health responses to sexual violence should be designed, and services taking into account its multifaceted nature should be provided.

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.

Agenda setting and framing of gender-based violence in Nepal: how it became a health issue

Gender-based violence (GBV) has been addressed as a policy issue in Nepal since the mid 1990s, yet it was only in 2010 that Nepal developed a legal and policy framework to combat GBV. This article draws on the concepts of agenda setting and framing to analyse the historical processes by which GBV became legitimized as a health policy issue in Nepal and explored factors that facilitated and constrained the opening and closing of windows of opportunity. The results presented are based on a document analysis of the policy and regulatory framework around GBV in Nepal. A content analysis was undertaken. Agenda setting for GBV policies in Nepal evolved over many years and was characterized by the interplay of political context factors, actors and multiple frames. The way the issue was depicted at different times and by different actors played a key role in the delay in bringing health onto the policy agenda. Women's groups and less powerful Ministries developed gender equity and development frames, but it was only when the more powerful human rights frame was promoted by the country's new Constitution and the Office of the Prime Minister that legislation on GBV was achieved and a domestic violence bill was adopted, followed by a National Plan of Action. This eventually enabled the health frame to converge around the development of implementation policies that incorporated health service responses. Our explicit incorporation of framing within the Kindgon model has illustrated how important it is for understanding the emergence of policy issues, and the subsequent debates about their resolution. The framing of a policy problem by certain policy actors, affects the development of each of the three policy streams, and may facilitate or constrain their convergence. The concept of framing therefore lends an additional depth of understanding to the Kindgon agenda setting model.

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 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.

Improved upper limits on the stochastic gravitational-wave background from 2009-2010 LIGO and Virgo data

Gravitational waves from a variety of sources are predicted to superpose to create a stochastic background. This background is expected to contain unique information from throughout the history of the Universe that is unavailable through standard electromagnetic observations, making its study of fundamental importance to understanding the evolution of the Universe. We carry out a search for the stochastic background with the latest data from the LIGO and Virgo detectors. Consistent with predictions from most stochastic gravitational-wave background models, the data display no evidence of a stochastic gravitational-wave signal. Assuming a gravitational-wave spectrum of Ω_{GW}(f)=Ω_{α}(f/f_{ref})^{α}, we place 95% confidence level upper limits on the energy density of the background in each of four frequency bands spanning 41.5-1726 Hz. In the frequency band of 41.5-169.25 Hz for a spectral index of α=0, we constrain the energy density of the stochastic background to be Ω_{GW}(f)<5.6×10^{-6}. For the 600-1000 Hz band, Ω_{GW}(f)<0.14(f/900  Hz)^{3}, a factor of 2.5 lower than the best previously reported upper limits. We find Ω_{GW}(f)<1.8×10^{-4} using a spectral index of zero for 170-600 Hz and Ω_{GW}(f)<1.0(f/1300  Hz)^{3} for 1000-1726 Hz, bands in which no previous direct limits have been placed. The limits in these four bands are the lowest direct measurements to date on the stochastic background. We discuss the implications of these results in light of the recent claim by the BICEP2 experiment of the possible evidence for inflationary gravitational waves.

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

Background

Researchers 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.

Methods

In-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.

Results

Findings 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.

Conclusions

The 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.

Search for gravitational waves associated with γ-ray bursts detected by the interplanetary network

We present the results of a search for gravitational waves associated with 223 γ-ray bursts (GRBs) detected by the InterPlanetary Network (IPN) in 2005-2010 during LIGO's fifth and sixth science runs and Virgo's first, second, and third science runs. The IPN satellites provide accurate times of the bursts and sky localizations that vary significantly from degree scale to hundreds of square degrees. We search for both a well-modeled binary coalescence signal, the favored progenitor model for short GRBs, and for generic, unmodeled gravitational wave bursts. Both searches use the event time and sky localization to improve the gravitational wave search sensitivity as compared to corresponding all-time, all-sky searches. We find no evidence of a gravitational wave signal associated with any of the IPN GRBs in the sample, nor do we find evidence for a population of weak gravitational wave signals associated with the GRBs. For all IPN-detected GRBs, for which a sufficient duration of quality gravitational wave data are available, we place lower bounds on the distance to the source in accordance with an optimistic assumption of gravitational wave emission energy of 10(-2)M⊙c(2) at 150 Hz, and find a median of 13 Mpc. For the 27 short-hard GRBs we place 90% confidence exclusion distances to two source models: a binary neutron star coalescence, with a median distance of 12 Mpc, or the coalescence of a neutron star and black hole, with a median distance of 22 Mpc. Finally, we combine this search with previously published results to provide a population statement for GRB searches in first-generation LIGO and Virgo gravitational wave detectors and a resulting examination of prospects for the advanced gravitational wave detectors.

Search for gravitational waves associated with γ-ray bursts detected by the interplanetary network

We present the results of a search for gravitational waves associated with 223 γ-ray bursts (GRBs) detected by the InterPlanetary Network (IPN) in 2005-2010 during LIGO's fifth and sixth science runs and Virgo's first, second, and third science runs. The IPN satellites provide accurate times of the bursts and sky localizations that vary significantly from degree scale to hundreds of square degrees. We search for both a well-modeled binary coalescence signal, the favored progenitor model for short GRBs, and for generic, unmodeled gravitational wave bursts. Both searches use the event time and sky localization to improve the gravitational wave search sensitivity as compared to corresponding all-time, all-sky searches. We find no evidence of a gravitational wave signal associated with any of the IPN GRBs in the sample, nor do we find evidence for a population of weak gravitational wave signals associated with the GRBs. For all IPN-detected GRBs, for which a sufficient duration of quality gravitational wave data are available, we place lower bounds on the distance to the source in accordance with an optimistic assumption of gravitational wave emission energy of 10(-2)M⊙c(2) at 150 Hz, and find a median of 13 Mpc. For the 27 short-hard GRBs we place 90% confidence exclusion distances to two source models: a binary neutron star coalescence, with a median distance of 12 Mpc, or the coalescence of a neutron star and black hole, with a median distance of 22 Mpc. Finally, we combine this search with previously published results to provide a population statement for GRB searches in first-generation LIGO and Virgo gravitational wave detectors and a resulting examination of prospects for the advanced gravitational wave detectors.

Constraints on cosmic strings from the LIGO-Virgo gravitational-wave detectors

Cosmic strings can give rise to a large variety of interesting astrophysical phenomena. Among them, powerful bursts of gravitational waves (GWs) produced by cusps are a promising observational signature. In this Letter we present a search for GWs from cosmic string cusps in data collected by the LIGO and Virgo gravitational wave detectors between 2005 and 2010, with over 625 days of live time. We find no evidence of GW signals from cosmic strings. From this result, we derive new constraints on cosmic string parameters, which complement and improve existing limits from previous searches for a stochastic background of GWs from cosmic microwave background measurements and pulsar timing data. In particular, if the size of loops is given by the gravitational backreaction scale, we place upper limits on the string tension Gμ below 10(-8) in some regions of the cosmic string parameter space.

Exploring experiences in peer mentoring as a strategy for capacity building in sexual reproductive health and HIV service integration in Kenya

Background

The Integra Initiative designed, tested, and adapted protocols for peer mentorship in order to improve service providers’ skills, knowledge, and capacity to provide quality integrated HIV and sexual and reproductive health (SRH) services. This paper describes providers’ experiences in mentoring as a method of capacity building. Service providers who were skilled in the provision of FP or PNC services were selected to undergo a mentorship training program and to subsequently build the capacity of their peers in SRH-HIV integration.

Methods

A qualitative assessment was conducted to assess provider experiences and perceptions about peer mentoring. In-depth interviews were conducted with twelve mentors and twenty-three mentees who were trained in SRH and HIV integration. Interviews were recorded, transcribed, and imported to NVivo 9 for analysis. Thematic analysis methods were used to develop a coding framework from the research questions and other emerging themes.

Results

Mentorship was perceived as a feasible and acceptable method of training among mentors and mentees. Both mentors and mentees agreed that the success of peer mentoring largely depended on cordial relationship and consensus to work together to achieve a specific set of skills. Mentees reported improved knowledge, skills, self-confidence, and team work in delivering integrated SRH and HIV services as benefits associated with mentoring. They also associated mentoring with an increase in the range of services available and the number of clients seeking those services. Successful mentorship was conditional upon facility management support, sufficient supplies and commodities, a positive work environment, and mentors selection.

Conclusion

Mentoring was perceived by both mentors and mentees as a sustainable method for capacity building, which increased providers’ ability to offer a wide range of and improved access to integrated SRH and HIV services.

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

Background

There 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.

Methods

Semi-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.

Results

Providers 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.

Conclusions

The 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.

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

BACKGROUND

In 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/DESIGN

A 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.

DISCUSSION

Integra addresses existing evidence gaps in the integration evaluation literature, building on the limited evidence from SSA and the expertise of its research partners.

TRIAL REGISTRATION

Current Controlled Trials NCT01694862.

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

Background

Malaysia 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.

Methods

In-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.

Results

The 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.

Conclusions

The 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.