Most health care providers interviewed defined IPV as physical and emotional abuse only, and included acts such as scolding, hitting, beating, threats, emotional stress and deprivation. Only a few providers mentioned sexual abuse among the types of acts that may characterise IPV. There seemed to be some hesitation in defining IPV, as if the providers never thought of it before. This could reflect the lack of any reflective training when the OSCC services were integrated.
Our study also shows that there is a predominant perception of IPV as a family or marital issue, and therefore IPV is not seen as a public health matter, despite the fact that some acknowledged the physical and emotional consequences resulting from it. In general, IPV is not perceived as a priority health issue, probably, as some doctors said, because it is not “life threatening”. Although many disagree with violence as a means to solve marital conflict and label it unfair, being part of a culture that closes its eyes to violence against women seems to impact on the views of some health care professionals, and therefore may fall down the list of priorities in a busy A&E context, where most of the abuse cases may be found.
The findings presented in this article support the view that providers’ attitudes to IPV and their perception of their role could affect the quality of the services they offer. Our interviews showed that there seemed to be a link between providers’ view of IPV and of their perceived role and how they therefore responded to survivors of IPV. Providers who demonstrated less understanding of the socio-cultural determinants of abuse were also the ones who were more likely to focus on the injuries. For those who were more focused on the physical consequences of IPV, the emotional part of the care was frequently disregarded or not seen as part of their role. Thus if providers thought that their role was just within the medical domain, they might fail to recognise the complex interaction between medical and psycho-social aspects of IPV care, and were less likely to refer women for any additional services they may need. This reflects the findings of another study which shows that the psycho-social aspects of medical care are often undervalued, where the emotional aspect of IPV care goes often ignored and its ‘social emergency’ is unrecognised
. This lack of awareness of the psycho-social dimensions of IPV risks perpetuating the view that IPV is purely about a couple quarrelling which in turn can lead to inappropriate responses that could jeopardise women’s safety and impact on women’s views of the services as they can lose trust in the provider.
The study findings show that many providers could not empathise with women’s decisions of going back to their husbands, and women’s evasiveness and underreporting were often causes of frustration for them. Their sense of medical responsibility towards abused women and the perception of their role as “solver of patients’ problems” might have limited their empathy towards women – especially the ones who chose to remain in abusive relationships and do not accept their advice. In fact, despite their willingness to help, some still lacked respect for women’s choices. This may arise more from lack of understanding about how difficult it is for women to disclose or to leave an abusive relationship, especially without specialist support (emotional, practical, legal etc.), and also derives from low understanding about IPV being characterised by power and control issues. For example the existing literature
[9, 23] found that health professionals often do not comprehend that some women do not really have any alternatives, and often feel incapable of trying to influence patients to report, seek additional care and in referring them appropriately.
Our data show that some doctors see women as an obstacle in their perceived self-efficacy in the management of IPV, and do not understand the barriers women may face such as their financial and legal dependency on their husband, or the blame of the community, and the shame of a divorce. Not all respondents really recognised the courage required from women when seeking help. Such an attitude could be linked to the way some providers tend to focus on “fixing” the medical aspect of abuse and would tell a woman to leave the husband, rather than thinking about what the woman may really want. This may reflect the medical culture, which is primarily curative and thus sees the provider as the main decision-maker
. This behaviour may also be related to a social class divide between doctors, who often belong to a higher socio-economic class than women who experienced abused. Moreover, this feeling of frustration, especially with “uncooperative women”, could be linked to the fact that providers think that it is difficult to offer an effective solution to women, especially when “successful” means convincing them to leave their husband. This issue is also raised in other settings
. Providers may lack understanding of women’s disempowerment – and the social context of abuse and the gender inequalities leading to IPV - due to their social distance from the community, and thus their lack of understanding of the problem. Moreover, there was no understanding that their role may be feeding in a longer term process of change among abused women. Even if a woman does not feel able to leave a violent relationship, she would like recognition and support from her health provider, without being pressured to any action. This issue has been explored in other industrialised countries
. Some women may not be ready to leave their husband and if health providers do not understand it, they may place women at more risk. More patient-centred and “stage-matched” interventions could be elaborated according to the various stages of change with regard to abuse
. Health professionals should at least support women’s decisions, and, in the long run, contribute to the women’s ability in making a change to their situation
. Referral to community support groups or NGOs, where they exist, can also be done and has been quite successful for example in Uganda (Michau and Nakar 2003).
There is the ongoing question about health care workers’ roles and in what ways they should be expected to help women. The contentious issue is whether their role should be purely medical or go beyond treatment
[27, 46]. The holistic management of IPV is not universally accepted as part of health personnel’s medical routine
[7, 47]. Our study shows that when providers follow the traditional role of treating and solving IPV as a “medical problem”, they tend to focus on the physical aspect of the injury and minimise the underlying cause of the problem. This does ensure that they at least treat the physical injuries of the patients, but it risks detaching providers from women’s personal experiences of IPV. Many practitioners seemed to feel helpless or inadequate when offering care to abused women. This was particularly true among staff at lower levels of hospital care, particularly where they had scarce resources, lack of local support services and limited access to training on IPV. Studies from other fields of health care also reported how some providers find offering emotional care to patients more difficult than any other aspects of clinical care
[26, 48]. The medicalised approach focuses mainly on the physical aspects of abuse and cannot help resolve women’s problem in the long term.
The feelings of inability or lack of self efficacy form an important part of the whole debate about what are realistic expectations for medical staff in terms of what they can do when addressing violence issues. In our study, providers’ sense of lack of self-efficacy is strongly bound up in the expectations of their professional role and what the meaning of successful patients’ outcome is. It seems that for many health providers the inability to resolve an abuse case – with a woman either reporting or leaving the husband – led to a feeling of inadequacy in their job.
On the other hand, our findings show that some doctors and nurses who would go beyond the limited medical role and argue they could provide more comprehensive care to women, taking a more proactive “advocate” role, offering advice and options of referrals and help channel women to additional care. This is an image that seems to be perceived primarily at tertiary care level, where they feel their role is to help women solve their problem not only by reassuring and calming them, but also by offering advice on support services. At district level, providers seemed to see their role as primarily being medical. Sometimes, this was due to unavailability of services on-site and locally, rather than unwillingness to help women. In general though, there seems to be a widespread uncertainty among providers about what their role should include. More sensitisation can help health care workers feel less inadequate.
The systematic and documented data collection and analysis employed in the study helped ensure that the process is auditable and replicable. Respondent validation was also used, which involved feeding back the research evidence to the research participants to confirm the findings. However, the study has several limitations. Firstly, it is based on a relatively small sample of practitioners and like all qualitative work is context-specific. However, it still sheds light on the dilemmas and frustrations that many health providers may face when responding to IPV, which could be addressed in training programmes and medical curricula to improve health responses to IPV. Secondly, it does not bring the perspective of the female clients directly, as they could not be interviewed because of ethical issues. However, the extensive literature research done to conceptualise this study does focus on women’s issues in order to voice their needs when implementing an integrated response.