Mapping and exploring health systems' response to intimate partner violence in Spain

Background: For a comprehensive health sector response to intimate partner violence (IPV), interventions should target individual and health facility levels, along with the broader health systems level which includes issues of governance, financing, planning, service delivery, monitoring and evaluation, and demand generation. This study aims to map and explore the integration of IPV response in the Spanish national health system. Methods: Information was collected on five key areas based on WHO recommendations: policy environment, protocols, training, monitoring and prevention. A systematic review of public documents was conducted to assess 39 indicators in each of Spain’s 17 regional health systems. In addition, we performed qualitative content analysis of 26 individual interviews with key informants responsible for coordinating the health sector response to IPV in Spain. Results: In 88% of the 17 autonomous regions, the laws concerning IPV included the health sector response, but the integration of IPV in regional health plans was just 41%. Despite the existence of a supportive national structure, responding to IPV still relies strongly on the will of health professionals. All seventeen regions had published comprehensive protocols to guide the health sector response to IPV, but participants recognized that responding to IPV was more complex than merely following the steps of a protocol. Published training plans existed in 43% of the regional health systems, but none had institutionalized IPV training in medical and nursing schools. Only 12% of regional health systems collected information on the quality of the IPV response, and there are many limitations to collecting information on IPV within health services, for example underreporting, fears about confidentiality, and underuse of data for monitoring purposes. Finally, preventive activities that were considered essential were not institutionalized anywhere. Conclusions: Within the Spanish health system, differences exist in terms of achievements both between regions and between the areas assessed. Progress towards integration of IPV has been notable at the level of policy, less outstanding regarding health service delivery, and very limited in terms of preventive actions.This study has been funded by a COFAS grant (supported by COFUND action within the Marie Curie Action People, in the Seventh Framework programme and the Swedish Council for Working Life and Social Research/FAS-Forskningsradet för arbetsliv och socialvetenskap)

Community perspectives on HIV, violence and health surveillance in rural South Africa : a participatory pilot study

Acknowledgements: The authors would like to acknowledge the study participants who contributed time and information and made significant contributions to the analysis, and the staff at the MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. Funding: The analysis presented in this paper is supported by Health Systems Research Initiative Development Grant from DFID/MRC/Wellcome Trust/ESRC (MR/N005597/1). The fieldwork was completed with the Umeå Centre for Global Health Research, with support from FORTE: Swedish Council for Health, Working Life and Welfare (grant No. 2006–1512). The Agincourt HDSS is supported by the School of Public Health, University of the Witwatersrand, South African Medical Research Council and the Wellcome Trust, UK (Grants 058893/Z/99/A; 069683/Z/02/Z; 085477/Z/08/Z; 085477/B/08/Z)Peer reviewedPublisher PD

Perspectives on intimate partner violence, focusing on the period of pregnancy

Målet med denna avhandling var att undersöka partnerrelaterat våld mot kvinnor i Sverige från olika perspektiv och med ett särskilt fokus på graviditetsperioden. Syftet var: 1) att ta reda på barnmorskors erfarenheter, attityder och rutiner angående partnerrelaterat våld mot gravida kvinnor inom mödravården; 2) att utforska hur personer som arbetar inom olika program för våldsbenägna män (inom och utom kriminalvården) talar om manligt och kvinnligt och om partnerrelaterat våld, speciellt i förhållande till graviditet; och 3) att belysa kvinnors erfarenheter av att bli och vara gravid samtidigt som de var utsatta för våld i relationen, samt deras möten med barnmorskorna på mödravårdscentralen. Data för tre studier samlades in under åren 1998-2003 med kvantitativa och kvalitativa metoder. En enkät skickades till alla yrkesverksamma mödravårdsbarnmorskor i Västerbotten och analyserades statistiskt och med innehållsanalys. Forskningsintervjuerna utfördes och analyserades enligt ’grundad teori’ (för att skapa teoretiska förklaringsmodeller), ’diskursanalys’ (för att visa hur ett gemensamt språkbruk konstruerar ’sanning’) och ’narrativ metod’ (för att tolka och återberätta innebörden i personliga berättelser). Resultaten från de studier som lade grunden till denna avhandling visar på problemets komplexitet, både från de professionellas och från kvinnornas perspektiv. Barnmorskorna (artikel I) var yrkeskunniga men också kunniga om partnerrelaterat våld mot kvinnor, men utan PM eller andra riktlinjer, så blev de osäkra och ställde sällan direkta frågor eftersom ämnet ansågs vara känsligt och tabubelagt. De professionella (artikel II-III) som arbetade med våldsbenägna män i olika program (inom eller utanför kriminalvården) krävde att män skulle ta ansvar för sitt våld. De ansåg att våldsamma män var tämligen vanliga män men avvikande i särskilda avseenden såsom i samspel, kommunikation, nära relationer och i deras kvinnosyn. De professionella beskrev stereotyper om könsskillnader och hur aggressivitet kan starta på olika sätt hos olika typer av män och ansåg också att graviditet kan utlösa konflikter och våld. Likväl så ingick i programmen vanligtvis inte känsliga frågor, om t.ex. graviditet och samlevnad, och trots en god vilja och avsikt att skapa en ’ny maskulinitet’, så tycktes deras strategier och tankegångar rent av kunna motverka deras egna goda syften. De nio intervjuade kvinnorna (artikel IV) som hade varit utsatta för våld beskrev hur deras liv hade varit komplicerade och blivit till en mardröm då deras hjärtevän hade förvandlats till en förövare. Två kvinnor bröt upp från sina relationer under graviditeten på grund av livshotande våld medan de andra för det mesta höll uppe en fasad och dolde det pågående våldet inför barnmorskan och andra alltmedan de gick balansgång mellan hopp och förtvivlan eller väntade på rätt tidpunkt att ge sig av. Förutom kvinnornas berättelser om partnerrelaterat våld under graviditet (artikel IV) så presenterades två professionella grupper och deras gemensamma svårigheter gällande tabun och känsliga frågor utanför det man vanligtvis sysslade med i sin profession (artikel I-III). Barnmorskorna var yrkeskunniga men hade ingen handlingsplan för att kunna bemöta och identifiera komplexiteten i våldsutsatta gravida kvinnors situation som ofta består i att dölja och balansera. De professionella i program för män konfronterade tydligt mäns våld och hade ambitionen att utmana deras maskulinitet, men då de i samtalen exempelvis förbisåg att ta upp vissa känsliga frågor kan utfallet ifrågasättas.The aim of this thesis was to examine - from different perspectives - intimate partner violence (IPV) against women, focusing on the period of pregnancy, with the object of increasing the available knowledge about this complex subject area, in a Swedish context. The specific aims were: i) to assess the experience, knowledge, attitudes and routines of midwives working in antenatal care regarding IPV against pregnant women; ii) to explore discourses with special reference to IPV, gender and the period of pregnancy of professionals running various intervention programs for men inclined to violence (outside or within the treatment of offenders); and iii) to illuminate experiences in women subjected to IPV by analyzing their stories about becoming and being pregnant as well as meeting antenatal care providers. Three studies were carried out using a combination of quantitative and qualitative methods. Questionnaires sent to all midwives working at antenatal care clinics in the county of Västerbotten were processed by statistical methods and content analysis. The qualitative research interviews followed the ‘grounded theory’, ‘discourse analysis’ or ‘narrative analysis’ approach. The results indicate the complexity of the problem of IPV from the viewpoints of both professional actors and the women. The midwives, although knowledgeable about IPV and certainly experts on pregnancy, felt uncertain regarding IPV and rarely asked direct questions of pregnant women, because the midwives perceived the subject to be difficult and taboo and they lacked guidelines to help them tackle the issue. The professionals in men’s programs intended men to take full responsibility for their own violent behavior. They viewed violent men as rather ordinary but yet deviant in certain respects such as in interplay, communication, relationships and in their views of women. The professionals described gender stereotypes and attributed and generalized certain masculine characteristics to aggressiveness. They also believed that pregnancy could be a potential trigger for conflicts and violence. Nevertheless, pregnancy and sensitive relational topics did not constitute significant parts of the intervention programs. Despite good intentions to change concepts of masculinity, the professionals’ discourses appeared to be rather lacking in reflection and even counter-productive. The women who had been subjected to violence described their complex lives as being terrible nightmares where their lovers turned into perpetrators. Two of the nine interviewed women left their relationships during pregnancy because of life-threatening violence whereas the others mostly kept up a front, hiding the IPV from the antenatal care staff and others while they trod a fine line between hope and despair or waited for the right moment to leave. In addition to women’s stories about IPV during pregnancy, two professional groups presented shared dilemmas regarding taboos and sensitive matters outside ordinary practice. Midwives were proficient but had no action plan to recognize and meet the complexity of the abused pregnant women’s situation involving concealment, balancing and decision-making. Professionals in programs for men were explicitly confronting men’s violence and wanted also to challenge masculinity in their clients. However, their discourse lacked depth by, for instance, their overlooking of sensitive relational topics in dialogues with men

B: Between desire and rape–narratives about being intimate partners and becoming pregnant in a violent relationship. Global Health Action 2013;(6)6:20984

Background: Women subjected to intimate partner violence (IPV) experience different forms of abuse. Sexual violence is often under-reported because physically abused women, in particular, might see forced sex as an obligatory part of the sexual interplay. Accordingly, abused women have less sexual autonomy and experience unplanned pregnancies more often than other women. Objective: To describe and analyse nine Swedish women's retrospective stories about IPV with a focus on power and coping strategies as intimate partners, particularly regarding experiences of sex, contraception, and becoming pregnant. Design: Nine qualitative interviews were carried out with women who had been subjected to very severe violence in their intimate relationships and during at least one pregnancy. The stories were analysed using 'Narrative method' with the emphasis on the women's lived experiences. Results: Despite the violence and many contradictory and ambivalent feelings, two of the women described having sex as desirable, reciprocal and as a respite from the rest of the relationship. The other seven women gave a negative and totally different picture, and they viewed sex either as obligatory or as a necessity to prevent or soothe aggression or referred to it as rape and as something that was physically forced upon them. The women's descriptions of their pregnancies ranged from being carefully planned and mostly wanted to completely unwelcome and including flawed contraceptive efforts with subsequent abortions. Conclusions: Women subjected to IPV have diverse and complex experiences that have effects on all parts of the relationship. Intimacy might for some turn into force and rape, but for others sex does not necessarily exclude pleasure and desire and can be a haven of rest from an otherwise violent relationship. Accordingly, women may tell stories that differ from the ones expected as 'the typical abuse story', and this complexity needs to be recognized and dealt with when women seek healthcare, especially concerning contraceptives, abortions, and pregnancies

Nursing in grief : Suicide survivors’ experiences of how suffering can be alleviated after a loved one’s suicide

Bakgrund: Suicid är ett folkhälsoproblem och i Sverige suiciderar cirka 1400 människor varje år. Sorgen efter en närståendes suicid leder till en kris och ett lidande för de anhöriga. Sjuksköterskans roll i den vårdande relationen blir att bekräfta dessa känslor och upplevelser hos den anhöriga. Syfte: Beskriva anhörigas upplevelser om hur lidandet kan lindras i sorgen efter en närståendes suicid. Metod: Studien är en kvalitativ analys av berättelser där tre självbiografier, tre antologier samt en rapport analyserades utifrån ett omvårdnadsperspektiv. Resultat: Resultatet visade tre kategorier med utgångspunkt från att lindra de anhörigas lidande. Att ta avsked av den döde visade sig vara viktigt i sorgeprocessen men att ändå vara lyhörd för individens val var viktigt. De anhöriga upplevde en unik känsla i sorgen efter en närståendes suicid och hade ett stort behov av att bli bekräftade i detta från omgivningen. Till sist hade de anhöriga skiftande behov av stöd i att leva vidare som kunde innefatta både läkemedelsbehandling, samtalsstöd och hjälp i det vardagliga. Slutsats: Genom resultatet kan studien belysa sjuksköterskans roll i den vårdande relationen som är att se och bekräfta de anhöriga som unika individer och fungera som koordinator gentemot den anhöriga med övriga hälso- och sjukvården.Background: Suicide is a public health problem and each year about 1,400 people commit suicide in Sweden. The grief after a loved one's suicide leads to a crisis and suffering of the survivors. The nurse's role in the caring relationship is to confirm the survivor’s feelings and experiences. Purpose: Describe suicide survivors’ experiences of how suffering can be alleviated after a loved one's suicide. Method: The study is a qualitative analysis of three autobiographies, three anthologies and a report, which were analyzed from a nursing perspective. Results: The result showed that saying goodbye to the deceased was important in the grieving process but also sensitivity to each survivor’s choice was paramount. Survivors experienced a unique feeling of grief after a loved one’s suicide and had a great need to be confirmed in this. Finally, the survivors had varying needs of support in order to continue living, which could include medical treatment, counseling or assistance in the everyday life. Conclusion: The results highlight the nurse's role in the caring relationship where acknowledging the survivors as unique individuals and coordinating their needs where among the nurse’s main tasks

Reproducing normative femininity : Women's evaluations of their birth experiences analysed by means of word frequency and thematic analysis

BACKGROUND: Given the significance of the birth experience on women's and babies' well-being, assessing and understanding maternal satisfaction is important for providing optimal care. While previous research has thoroughly reviewed women's levels of satisfaction with the childbirth experience from a multitude of different angles, there is a dearth of papers that use a gender lens in this area. The aim of this study is to explore through a gender perspective the circumstances attributed to both women's assessment of a positive birth experience and those which contribute to a lack of satisfaction with their birth experience. METHODS: Through the use of a local birth evaluation form at a Swedish labour ward, 190 women gave written evaluations of their birth experiences. The evaluations were divided into groups of positive, ambiguous, and negative evaluations. By means of a latent and constructionist thematic analysis based on word count, women's evaluations are discussed as reflections of the underlying sociocultural ideas, assumptions, and ideologies that shape women's realities. RESULTS: Three themes were identified: Grateful women and nurturing midwives doing gender together demonstrates how a gender-normative behaviour may influence a positive birth experience when based on a reciprocal relationship. Managing ambiguous feelings by sympathising with the midwife shows how women's internalised sense of gender can make women belittle their negative experiences and refrain from delivering criticism. The midwifery model of relational care impeded by the labour care organisation describes how the care women receive during labour and birth is regulated by an organisation not always adapted to the benefit of birthing women. CONCLUSIONS: Most women were very satisfied, predominantly with emotional support they received from the midwives. The latent constructionist thematic analysis also elicited women's mixed feelings towards the birth experience, with the majority of negative experiences directed towards the labour care organisation. Recognising the impact of institutional and medical discourses on childbirth, women's birth evaluations demonstrate the benefits and challenges of gender-normative behaviour, where women's internalised sense of gender was found to affect their experiences. A gender perspective may provide a useful tool in unveiling gender-normative complexities surrounding the childbirth experience

'The public health turn on violence against women' : Analysing Swedish healthcare law, public health and gender-equality policies

This article focuses on policy and law concerning violence against women as a public health issue. In Sweden, violence against women is recently recognized as a public health problem; we label this shift "The public health turn on violence against women". The new framing implies increased demands on the Swedish healthcare sector and its’ ability to recognise violence and deal with it in terms of prevention and interventions. The aim was to describe and discuss the main content and characteristics of Swedish healthcare law, and national public health and gender-equality policies representing the public health turn on violence against women. Through discursive policy analysis, we investigate how the violence is described, what is regarded to be the problem and what solutions and interventions that are suggested in order to solve the problem. Healthcare law articulates violence against women as an ordinary healthcare issue and the problem as shortcomings to provide good healthcare for victims, but without specifying what the problem or the legal obligation for the sector is. The public health problem is rather loosely defined, and suggested interventions are scarce and somewhat vague. The main recommendations for healthcare are to routinely ask patients about violence exposure. Violence against women is usually labelled "violence within close relationships" in the policies, and it is not necessarily described as a gender equality problem. While violence against women in some policy documents is clearly framed as a public health problem, such a framing is absent in others, or is transformed into a gender-neutral problem of violence within close relationships. It is not clearly articulated what the framing should lead to in terms of the healthcare sector's obligations, interventions and health promotions, apart from an ambivalent discourse on daring to ask about violence

Prevalence and correlates of gender inequitable norms among young, church-going women and men in Kinshasa, Democratic Republic of Congo

BACKGROUND: Prolonged political instability may have exacerbated gender inequitable beliefs in the Democratic Republic of Congo (DRC). The aim of this study was to assess attitudes related to gender-equitable norms and its determinants among young, church-going women and men in Kinshasa, DRC. METHOD: Data were collected through a cross-sectional survey with 291 church-going women and 289 men aged 18-24 years old, residing in three disadvantaged communes of Kinshasa. Variables included sociodemographic characteristics, attitudes towards gender equality, and responses to issues related to the gender-equitable men (GEM) scale. The GEM scale is a 24 item-questionnaire developed to measure attitudes towards gender equitable norms. Logistic regression was applied to discover the associations between the independent variables and the GEM outcome. RESULTS: Our study reflected the existence of attitudes hampering gender equality that were endorsed by both women and men. For example, 91.4% of women and 83% of men agreed with the statement "a woman's most important role is to take care of her home and cook for her family". Similarly, 88.3% of women and 82.9% of men concurred with the idea that men need more sex than women. These findings coexisted with a few equitable norms, because 93.7% of women and 92.3% of men agreed that a man and a woman should decide together if they want to have children. A positive association was found in both women and men between being educated, being single and separated and having supportive attitudes towards gender equality and a higher GEM scale score. Residency in Camp Luka and Masina was also a significant social determinant associated with equitable gender norms among men whilst job status was only significant among women. CONCLUSION: While both women and men had high levels of gender inequitable norms, those with more education, single, and with supportive attitudes to gender equality had high GEM scale scores. The results highlight an urgent need for the church to challenge and change gender norms among church youths

The Health Extension Program and Its Association with Change in Utilization of Selected Maternal Health Services in Tigray Region, Ethiopia : A Segmented Linear Regression Analysis

BACKGROUND: In 2003, the Ethiopian Ministry of Health established the Health Extension Program (HEP), with the goal of improving access to health care and health promotion activities in rural areas of the country. This paper aims to assess the association of the HEP with improved utilization of maternal health services in Northern Ethiopia using institution-based retrospective data. METHODS: Average quarterly total attendances for antenatal care (ANC), delivery care (DC) and post-natal care (PNC) at health posts and health care centres were studied from 2002 to 2012. Regression analysis was applied to two models to assess whether trends were statistically significant. One model was used to estimate the level and trend changes associated with the immediate period of intervention, while changes related to the post-intervention period were estimated by the other. RESULTS: The total number of consultations for ANC, DC and PNC increased constantly, particularly after the late-intervention period. Increases were higher for ANC and PNC at health post level and for DC at health centres. A positive statistically significant upward trend was found for DC and PNC in all facilities (p<0.01). The positive trend was also present in ANC at health centres (p = 0.04), but not at health posts. CONCLUSION: Our findings revealed an increase in the use of antenatal, delivery and post-natal care after the introduction of the HEP. We are aware that other factors, that we could not control for, might be explaining that increase. The figures for DC and PNC are however low and more needs to be done in order to increase the access to the health care system as well as the demand for these services by the population. Strengthening of the health information system in the region needs also to be prioritized