Perceptions, experiences and health sector responses to intimate partner violence in Malawi: the centrality of context

BACKGROUND: The health sector has ‘duty of care’ to provide comprehensive health services to survivors of violence, to act as a referral point, to collect and document evidence, to report data on violence and to engage in preventive services. In Malawi, 48% of women experience some form of intimate partner violence (IPV) and a significant number report conditions requiring health care services, although few actually report to health services, which are in turn limited in scope and availability. Understanding how health care providers, relevant stakeholders and IPV survivors perceive the role of health care services in IPV is necessary to promote the development of context-relevant and sustainable health care interventions. AIM: To understand the health service responses to IPV in Malawi from a wide range of perspectives OBJECTIVES: i) to critically analyze written legislation, policy and strategy documents in relation to IPV and the health sector in Malawi; ii) to describe the perceptions and experiences of IPV and of health sector responses among survivors of violence, community members, health care workers and other key stakeholders in Malawi; iii) to estimate the extent of intimate partner and sexual violence from a health service uptake perspective using proxy determinants at one referral hospital in Malawi iv) To explore the policy implications of the study findings for the health sector responses in Malawi METHODS: In 2011, a multi-method situation analysis was conducted in three areas of Blantyre district, with additional data collected in Mangochi and Lilongwe districts. Seventeen relevant national documents were analyzed. A total of 10 focus group discussions (FGDs), 2 small groups and 14 individual interviews (IIs) were conducted with health care providers; 18 FGDs and one small group discussion were conducted with male and female, urban and rural community members; 12 in-depth interviews (IDIs) with survivors; 26 key informant interviews (KIIs) with donor agencies, GBV service providers, religious institutions; police officers and other stakeholders were conducted. A review of 3,567 register records for the month of January 2011 was done in Queen Elizabeth Central Hospital and police records on violence cases in Blantyre for the same month were reviewed. Qualitative data was analyzed using the ‘framework’ approach, assisted by NVIVO 9 software. Hospital records were analyzed using Epi Info™. Feminist approaches and the ecological framework for analysis of violence informed data analysis and interpretation. A range of quality assurance measures were undertaken and data were triangulated across all methods: policy analysis, interviews and records reviews. FINDINGS: A review of legislation and policy combined with qualitative stakeholder interviews revealed conflicts, gaps and lack of awareness of the available documents that undermined coordinated health sector responses. Survivors, community members and health care workers revealed that IPV is perceived as a massive, though under-recognised problem. IPV in its various forms was seen as widespread and normalised, except perhaps in the perceived severe forms (such as femicide and child rape). IPV, though considered as shameful, was not necessarily a very private matter with involvement of neighbours, families, friends and significant others. Various factors at individual, interpersonal, society and institutional levels were described as affecting under-reporting, access to services and responses from sources of support. The review of registered data confirmed that IPV is generally underreported in health services and that relying on trauma as a proxy for IPV against women would prove difficult to implement. This multi-method approach highlighted the importance of diagnostic identification and the difficulties of universal screening. The actual role of health services in IPV seemed fuzzy from the service user’s perspectives and narrowly confined to the bio-medical model or acute model of health service provision. However, both potential service users and health care providers were optimistic about new developments such as ‘One Stop Centres’ and about the potential role of health services, particularly those linked to HIV programmes. They suggested these be provided as a continuum from prevention to rehabilitation. CONCLUSIONS: This study found a range of laws and policies that define and promote action to prevent IPV in Malawi. These have had some positive influences on both community norms and health sector responses. However, ineffective promotion has limited their effectiveness. In addition there are gaps and inconsistencies that reduce their potential in guiding the health sector response to IPV. The study explored stakeholders’ perceptions of IPV, the health sector response and the factors shaping it. This revealed a complex web of interconnected socio-economic, cultural, political and institutional factors. Perceptions of violence are culturally normative and related to gender roles and expectations. The inclusion of male voices on IPV against men, and using emic definitions of violence revealed conflicts between women’s and men’s interpretations of IPV, particularly with regard to sexual violence and the transgression of gender and marital roles. The specific socio-economic and cultural context strongly favours a conflict resolution model of responding to violence, which raises questions about the mandate and the potential roles of the health sector. Most stakeholders perceive IPV as a significant problem and recognise multiple impacts on health. However there is a clear disconnect between the magnitude of the problem and the health sector response. Nevertheless, the health sector is well placed to play a leadership role and has some resources, such as HIV Testing and Counselling staff and curricula to offer in a multi-sectoral response. Proxy determinants as reflected in the health service registers proved to be inadequate due to poor reporting and recording, and under-reporting to health services. Under-reporting was influenced by a range of inter-connected barriers to formal help-seeking, including normative attitudes and ineffective responses by both informal and formal sources of support. However, knowledge was generated about the challenges to recording and reporting IPV in this setting. The study findings suggested a number of key opportunities for improving the health sector response to IPV in Malawi that may be appropriate in this specific context and considered their potential sustainability

Regulation of HIV self-testing in Malawi, Zambia and Zimbabwe: a qualitative study with key stakeholders.

INTRODUCTION: HIV self-testing (HIVST) is being introduced as a new way for more undiagnosed people to know their HIV status. As countries start to implement HIVST, assuring the quality and regulating in vitro diagnostics, including HIVST, are essential. We aimed to document the emerging regulatory landscape and perceptions of key stakeholders involved in HIVST policy and regulation prior to implementation in three low- and middle-income countries. METHODS: Between April and August 2016, we conducted semi-structured interviews in Malawi, Zambia and Zimbabwe to understand the relationships between different stakeholders on their perceptions of current and future HIVST regulation and the potential impact on implementation. We purposively sampled and interviewed 66 national-level key stakeholders from the Ministry of Health and the regulatory, laboratory, logistical, donor and non-governmental sectors. We used a thematic approach to analysis with an inductively developed common coding framework to allow inter-country comparison of emerging themes. RESULTS: In all countries, the national reference laboratory was monitoring the quality of HIVST kits entering the public sector. In Malawi, there was no legal mandate to regulate medical devices, in Zambia one regulatory body with a clear mandate had started developing regulations and in Zimbabwe the mandate to regulate was overlapping between two bodies. Stakeholders indicated that they had a poor understanding of the process and requirements for HIVST regulation, as well as lack of clarity and coordination between organizational roles. The need for good collaboration between sectors, a strong post-market surveillance model for HIVST and technical assistance to develop regulators capacity was noted as priorities. Key informants identified technical working groups as a potential way collaboration could be improved upon to accelerate the regulation of HIVST. CONCLUSION: Regulation of in vitro diagnostic devices, including HIVST, is now being recognized as important by regulators after a regional focus on pharmaceuticals. HIVST is providing an opportunity for each country to develop similar regulations to others in the region leading to a more coherent regulatory environment for the introduction of new devices

Perceptions of the mental health impact of intimate partner violence and health service responses in Malawi

Background and objectives: This study explores the perceptions of a wide range of stakeholders in Malawi towards the mental health impact of intimate partner violence (IPV) and the capacity of health services for addressing these. Design: In-depth interviews (IDIs) and focus group discussions (FGDs) were conducted in three areas of Blantyre district, and in two additional districts. A total of 10 FGDs, 1 small group, and 14 IDIs with health care providers; 18 FGDs and 1 small group with male and female, urban and rural community members; 7 IDIs with female survivors; and 26 key informant interviews and 1 small group with government ministry staff, donors, gender-based violence service providers, religious institutions, and police were conducted. A thematic framework analysis method was applied to emerging themes. Results: The significant mental health impact of IPV was mentioned by all participants and formal care seeking was thought to be impeded by social pressures to resolve conflict, and fear of judgemental attitudes. Providers felt inadequately prepared to handle the psychosocial and mental health consequences of IPV; this was complicated by staff shortages, a lack of clarity on the mandate of the health sector, as well as confusion over the definition and need for ‘counselling’. Referral options to other sectors for mental health support were perceived as limited but the restructuring of the Ministry of Health to cover violence prevention, mental health, and alcohol and drug misuse under a single unit provides an opportunity. Conclusion: Despite widespread recognition of the burden of IPV-associated mental health problems in Malawi, there is limited capacity to support affected individuals at community or health sector level. Participants highlighted potential entry points to health services as well as local and national opportunities for interventions that are culturally appropriate and are built on local structures and resilience

Prevalence and associated factors of intimate partner violence amongst women attending prevention of mother to child transmission services in Blantyre, Malawi

Background: Intimate partner violence (IPV) during the perinatal period and when one is HIV-positive is a great concern because of the physical and mental impacts it has on health and on adherence to prevention of mother to child transmission (PMTCT) services. However, factors associated with IPV amongst perinatal women on PMTCT services are not adequately explored in Malawi. The aim of this study was to estimate the various types of IPV and the associated factors amongst HIV-positive pregnant and postnatal women in selected health centres in Blantyre district.Methods: In this cross-sectional study, we recruited 200 HIV-positive women from antenatal, postnatal and antiretroviral therapy (ART) clinics from four selected primary care facilities of Blantyre district. Data were collected between March and May 2018.Results: A total of 50% of the participants reported to have experienced either physical, psychological or sexual violence from their partner in the last 12 months. The multivariate logistic regression model showed that feelings about safety of the relationship and depression were the only factors that were consistently associated with IPV in the last 12 months (p = 0.001, Pseudo R2 = 0.20).Conclusion: The presence of depression and safety concerns amongst our study participants calls for serious prioritisation of psychological interventions and risk assessment in the management of HIV-positive perinatal mothers who report IPV cases

Using an innovative mixed method methodology to investigate the appropriateness of a quantitative instrument in an African context: Antiretroviral treatment and quality of life

The relationship between quality of life (QoL) and antiretroviral treatment (ART) has mainly been studied using quantitative scales often not appropriate for use in other contexts and without taking peoples\u27 lived experiences into consideration. Sub-Saharan Africa has the highest incidence of HIV and AIDS yet there is paucity in research done on QoL. This research report is intended to give an account of the use of a mixed method convergent parallel design as a novice approach to evaluate an instrument\u27s context specificity, appropriateness and usefulness in another context for which it was designed. Data were collected through a qualitative exploration of the experiences of QoL of people living with HIV or AIDS (PLHA) in Africa since being on ART, as well as the quantitative measurements obtained from the HIV/AIDS-targeted quality of life (HAT-QoL) instrument. This study was conducted in three African countries. Permission and ethical approval to conduct the study were obtained. Purposive voluntary sampling was used to recruit PLHA through mediators working in community-based HIV/AIDS organisations and health clinics. Interviews were analysed through open coding and the quantitative data through descriptive statistics and the Cronbach\u27s alpha coefficient. A much wider range and richness of experiences were expressed than measured by the HAT-QoL instrument. Although an effective instrument for use in the USA, it was found not to be sensitive, appropriate and useful in an African context in its present form. The recommendations focus on adapting the instrument using the data from the in-depth interviews or to develop a context-sensitive instrument that could measure QoL of PLHA in Africa

What Should the Ideal HIV Self-Test Look Like? A Usability Study of Test Prototypes in Unsupervised HIV Self-Testing in Kenya, Malawi, and South Africa

HIV self-testing (HIVST) is increasingly being sought and offered globally, yet there is limited information about the test features that will be required for an HIV self-test to be easy to use, acceptable to users, and feasible for manufacturers to produce. We conducted formative usability research with participants who were naïve to HIVST using five prototypes in Kenya, Malawi, and South Africa. The tests selected ranged from early-stage prototypes to commercially ready products and had a diverse set of features. A total of 150 lay users were video-recorded conducting unsupervised self-testing and interviewed to understand their opinions of the test. Participants did not receive a test result, but interpreted standardized result panels. This study demonstrated that users will refer to the instructions included with the test, but these can be confusing or difficult to follow. Errors were common, with less than 25 % of participants conducting all steps correctly and 47.3 % of participants performing multiple errors, particularly in sample collection and transfer. Participants also had difficulty interpreting results. To overcome these issues, the ideal HIV self-test requires pictorial instructions that are easy to understand, simple sample collection with integrated test components, fewer steps, and results that are easy to interpret