title: Perceptions, experiences and health sector responses to intimate partner violence in Malawi: the centrality of context
Creators: name: Chepuka, Lignet
Publisher: name: University of Liverpool Repository
Year: 2013

description: 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.