Innovations in implementing a health systems response to violence against women in 3 tertiary hospitals of Maharashtra India: Improving provider capacity and facility readiness

Abstract

Background Violence against women [VAW] is an urgent public health issue and health care providers [HCPs] are in a unique position to respond to such violence within a multi-sectoral health system response. In 2013, the World Health Organization (WHO) published clinical and policy guidelines (henceforth – the Guidelines) for responding to intimate partner violence and sexual violence against women. In this practical implementation report, we describe the adaptation of the Guidelines to train HCPs to respond to violence against women in tertiary health facilities in Maharashtra, India. Methods We describe the strategies employed to adapt and implement the Guidelines, including participatory methods to identify and address HCPs’ motivations and the barriers they face in providing care for women subjected to violence. The adaptation is built on querying health-systems level enablers and obstacles, as well as individual HCPs’ perspectives on content and delivery of training and service delivery. Results The training component of the intervention was delivered in a manner that included creating ownership among health managers who became champions for other health care providers; joint training across cadres to have clear roles, responsibilities and division of labour; and generating critical reflections about how gender power dynamics influence women's experience of violence and their health. The health systems strengthening activities included establishment of standard operating procedures [SOPs] for management of VAW and strengthening referrals to other services. Conclusions In this intervention, standard training delivery was enhanced through participatory, joint and reflexive methods to generate critical reflection about gender, power and its influence on health outcomes. Training was combined with health system readiness activities to create an enabling environment. The lessons learned from this case study can be utilized to scale-up response in other levels of health facilities and states in India, as well as other LMIC contexts. Plain language summary Violence against women affects millions of women globally. Health care providers may be able to support women in various ways, and finding ways to train and support health care providers in low and middle-income countries to provide high-quality care to women affected by violence is an urgent need. The WHO developed Clinical and Policy Guidelines in 2013, which provide guidance on how to improve health systems response to violence against women. We developed and implemented a series of interventions, including training of health care providers and innovations in service delivery, to implement the WHO guidelines for responding to violence against women in 3 tertiary hospitals of Maharashtra, India. The nascent published literature on health systems approaches to addressing violence against women in low and middle-income countries focuses on the impact of these interventions. This practical implementation report focuses on the interventions themselves, describes the processes of developing and adapting the intervention, and thus provides important insights for donors, policy-makers and researchers.

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

“…Although training of all staff is an enabling factor for implementing IPV care [ 14 ], it is not sufficient without staff motivation and self-efficacy [ 9 ]. Addressing staff values and attitudes around IPV and harnessing support and commitment from health managers are also necessary to ensure a conducive and enabling environment [ 14 , 20 , 38 , 42 ], especially when paired with supportive interdisciplinary teams [ 10 , 37 ].…”

“…Health system readiness focuses on how prepared healthcare systems and institutions - including providers and potential users - are to accept and implement the changes brought about by the integration of the new programme. In IPV research, such assessment is often limited to individual provider readiness [ 16 , 19 ] or facility-level (or service-level) factors that need to be strengthened [ 15 ] with less attention – until recently [ 10 , 20 ] - to broader health system dimensions (e.g. organisational issues such as governance and leadership) and their interactions [ 16 , 21 ], which are harder to change.…”

Assessing the Nepalese health system’s readiness to manage gender-based violence and deliver psychosocial counselling

“…These materials have been prominently displayed on the health facility walls, guiding women on whom to approach regarding their experiences of violence ( World Health Organization, CEHAT and HRP, 2021 ). Moreover, they serve to emphasize the availability of assistance for women experiencing violence, affirming their right to a violence free life ( Gadappa et al ., 2022 ). In Nepal, similar IEC materials have been employed to disseminate information about OCMC and their associated services ( Ministry of Health and Population, 2017 ).…”

Healthcare Providers’ Perceptions and Experiences of Training to Respond to Violence against Women: Results from a Qualitative Study

“…Evidence that training alone is not sufficient but requires health system changes has been reflected in the global evidence base, and this evidence was used to inform the recommendations of the WHO clinical and policy guidelines that were the basis for this intervention and study [ 12 ]. In line with this global body of evidence, the interventions in this study described elsewhere [ 37 ] also included health system strengthening components, focusing on infrastructure changes, supportive supervision, mentoring, documentation systems, and the creation of champions. Our findings reflect that the training along with the system strengthening components had some positive impacts.…”

“…It highlighted the need for developing and testing innovations in how the health sector could respond to violence against women, including through telemedicine and other digital approaches. The qualitative perspectives of HCPs on the content, structure, and implementation of the training in this context can inform the development and implementation of trainings in other settings in LMIC [ 37 ]. These findings add to a nascent evidence base concerning HCPs’ experiences and perceptions of training in response to VAW in LMICS.…”