Elsevier

The Lancet

Volume 359, Issue 9316, 27 April 2002, Pages 1509-1514
The Lancet

Series
Dilemmas and opportunities for an appropriate health-service response to violence against women

https://doi.org/10.1016/S0140-6736(02)08417-9Get rights and content

Summary

This article is an overview of the role of health services in secondary and tertiary prevention of intimate partner violence. In it, I review the evidence, which comes mostly from developed countries, on the effectiveness and limitations of in-service training programmes to identify and care for women who have experienced intimate partner violence. I also discuss recent initiatives in developing countries to integrate concerns on gender-based violence into health-care services at different levels, some of the dilemmas and challenges posed by the current approaches to intimate partner violence, and recommendations for future interventions.

Section snippets

Ensuring safety for women

Some argue that asking women about partner violence in a sympathetic and non-judgmental manner can in itself be therapeutic (figure 2). This approach can signal that someone is interested, that the woman is not alone, and that there is a space in which she can talk about the problem if and when she wishes to do so. Many women, regardless of whether they had experienced intimate partner violence, would welcome health providers asking questions on abuse—even if they chose not to disclose

Interventions in health-care settings

Reviews of in-service training and screening programmes have shown the lack of formal assessment of such interventions and that there are few data on their effectiveness.15, 16 The few assessments that have been done focus on process measures, such as increases in identification rates, and lack well defined, long-term outcome measures.17, 18 Experiences have been documented almost exclusively in developed countries, particularly the USA. However, initiatives are now also underway in developing

Training in health-care settings

Many problems with implementation of appropriate interventions could arise from inadequate training. Although some efforts32, 33 have begun to integrate violence against women or family violence into undergraduate curricula of doctors and nurses, most health professionals will graduate without having heard about these issues. These issues should be given higher priority since education would provide the basis for later in-service training. A review of primary care, obstetrics and gynaecology,

Gender and power in the health system

The inequalities between women and men that are common in most societies are usually also reflected in the health sector. Warshaw40 has discussed extensively how the medical model and its institutions restrict the possibilities of responding to women experiencing violence. She emphasises the need for structural transformation as essential for development of an effective health-service response to women in abusive situations. This change is especially important in settings in which violence

Context specific models

The level of intervention that is appropriate will vary between settings depending on the availability of human and financial resources and of services to which health workers can refer women. Different levels of response are possible, ranging from posters or other messages highlighting the problem to more proactive interventions. Even within one health-care setting such as a hospital, there may be great variation between units in what is feasible. Protocols, training, and information should be

Assessment and outcome measures

Although asking questions about abuse is an intervention in its own right and might be effective, the experience of most clinicians is that an appropriate response is needed when women have been identified as being abused. However, screening might become an end in itself rather than a first step towards making available or providing access to a range of services and responses. In some cases, a list of telephone numbers or possible places for referral can be provided, and in others referral to a

Conclusions and recommendations

Health services are increasingly recognised as being able to play an important part in addressing the more common forms of violence against women, especially in secondary and tertiary prevention. A consensus is also growing on the need to assess and identify effective health-sector interventions to convince health providers and policy makers of the value of these interventions. Although research on interventions is methodologically difficult and can be expensive, without a concerted effort in

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