Avni Amin

Objective: The field of violence against women and girls (VAWG) prevention research has rapidly advanced, with ample evidence now demonstrating that VAWG is preventable. The aim of this systematic review of reviews is to update the evidence that underpins the RESPECT women framework with the newest available evidence from 2013 onward. Methods: Academic and non-academic databases were searched using terms related to VAWG prevention (January 2013–April 2022). Evaluations had to have a target population of women or girls aged 10 and older. Data were extracted from included reviews, and AMSTAR-2 was used to assess the risk of bias in systematic reviews. The primary outcome of interest was change in any form of VAWG, including physical, sexual and emotional intimate partner violence and sexual violence and harassment from non-partners, including child and adolescent sexual abuse. Results: From the thousands of articles screened, 178 were included in this study. Six (3%) reviews focused on interventions that aim to strengthen relationship skills, 14 (8%) focused on empowerment of women and girls, 79 (44%) on services for survivors, 5 (3%) on poverty reduction, 16 (9%) on creating safe environments, 36 (20%) on preventing child and adolescent abuse and 22 (12%) on transforming gender attitudes, beliefs and norms. Little new evidence has emerged to meaningfully change the nature and strength of evidence for interventions related to relationship skills strengthening and poverty reduction. However, there is new evidence to reflect the effectiveness of select types of interventions across settings in the other five strategies. Conclusion: Despite progress in VAWG prevention research, significant gaps in the evidence base persist. Further research is needed to explore intervention areas and marginalised populations in various contexts. Several programmatic approaches exhibiting efficacy in low-income and middle-income countries remain unexplored and unevaluated in high-income countries, and vice versa, warranting further adaptation and evaluation.

Introduction: Violence against women (VAW) during the COVID-19 pandemic was described as the ‘shadow pandemic’ with an increase in reports of VAW. As countries now focus on becoming more resilient to future pandemics, it is critical to understand what we learnt about evidence on VAW burden, prevention, and response during the COVID-19 pandemic. The WHO commissioned this scoping review to gain an understanding of the research evidence on VAW during COVID-19 and to inform future pandemic preparedness efforts. Methods: Terms relating to VAW and COVID-19 were used to search six databases between 1 January 2020 and 11 February 2023, inclusive of all study designs. Data on thematic focus (ie, burden of violence and/or interventions/services), types of violence, study design, study setting and participant characteristics were synthesised. Results: Of 25 080 identified records, 694 publications were reviewed in full text and 419 publications were included. The majority (>95%) of the published research was devoted to documenting the burden of VAW, while only 6.2% studied solutions (interventions/services), with even less emphasis on identifying how to prevent VAW in a pandemic context (1%). Gaps in research on VAW that existed prior to the pandemic on women who face multiple intersecting forms of disadvantage endured. Outstanding also was the gap in research on digital-mediated violence (<5%), even as reports of online facilitated violence soared. Additionally, gaps in evidence on specific types of violence such as femicide, forced marriage and acid attacks persisted. Conclusion: That VAW will be a critical concern, and its impacts worsened during pandemics in the future is certain. The research community does not need to spend more on understanding the burden of forms of VAW but pivot to research to adapt and innovate how to deliver prevention and support services, especially to populations who are disproportionately impacted. In addition to addressing this broader gap in prevention and response during pandemics, further evidence is required on the specific area of technology-mediated violence, femicide, forced marriage and acid attacks.

Healthcare providers (HCPs) can support women affected by violence, providing a safe way for women to disclose experiences of violence and mitigating violence against women (VAW) through the identification of cases in routine clinical practice. We conducted in-depth interviews and focus group discussions with HCPs in three tertiary facilities in Maharashtra, India, who had participated in training using the World Health Organization curriculum, adapted for the Indian context. n = 21 HCPs participated in in-depth interviews and n = 10 nurses participated in two focus group discussions. The respondents indicated that the training approach and content were acceptable and that the skills learned during the training were feasible to implement. A shift in perspective from viewing VAW as a private issue to understanding it as a health issue facilitated HCPs’ response. The training enabled HCPs to recognize barriers faced by women in disclosing violence and their role in supporting disclosure. HCPs reported barriers to providing care for survivors of violence, including a lack of human resources, the time during regular clinical practice, and a lack of strong referral networks. These data can be utilized to inform other efforts to train HCPs in facilities in this setting and provide evidence for ways to improve health systems’ responses to VAW in low-and middle-income country settings.

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.

Gender equality is achievable and an imperative

Background: Globally, including in low- and middle-income [LMIC] countries, there is increased attention to and investment in interventions to prevent and respond to violence against women; however, most of these approaches are delivered outside of formal or informal health systems. The World Health Organization published clinical and policy guidelines Responding to intimate partner violence and sexual violence against women in 2013. Further evidence is needed concerning implementation of the Guidelines, including how health care providers perceive training interventions, if the training approach meets their needs and is of relevance to them and how to ensure sustainability of changes in practice due to training. This manuscript describes a study protocol for a mixed methods study of the implementation of the Guidelines and related tools in tertiary hospitals in two districts in Maharashtra, India. Methods: The study will employ a mixed-methods study design. A quantitative assessment of health care providers’ and managers’ knowledge, attitudes, and practices will be conducted pre, post, and 6 months after the training. Qualitative methods will include a participatory stakeholders’ meeting to inform the design of the training intervention design, in-depth interviews [IDIs] and focus-group discussions [FGDs] with health care providers and managers 3–6 months after training, and IDIs with women who have disclosed violence to a trained health care provider, approximately 6 months after training. The study will also validate two tools: a readiness assessment of health facilities and a health management information system form in a facility register format which will be used to document cases of violence. Discussion: The multiple components of this study will generate data to improve our understanding of how implementation of the Guidelines works, what barriers and facilitators to implementation exist in this context, and how current implementation practices result in changes in terms of health services and providers’ practices of responding to women affected by violence. The results will be useful for governmental and non-governmental and United Nations Agency efforts to improve health systems and services for women affected by violence, as well as for researchers working on health systems responses to violence against women in India and possibly other contexts.

(2019). Violence against women: where are we 25 years after ICPD and where do we need to go? Sexual and Reproductive Health Matters: Vol. 27, Open Issue, pp. 1-3.

In April 2016, the Population Council, in partnership with the World Health Organization (WHO) and the International Consortium for Emergency Contraception, convened a regional meeting in Lusaka, Zambia, geared toward supporting countries in East and Southern Africa in meeting their obligations under the Maputo Protocol. These obligations include expanding access to women’s reproductive health services – especially women survivors of sexual violence. Government and civil society representatives from six countries participated: Botswana, Ethiopia, Kenya, Malawi, Rwanda, and Zambia. Countries were selected based on to their being priority settings for the projects that sponsored the meeting, coupled with the fact that they were each far enough along in addressing post-rape care to be able to develop concrete policy, programming, and/or legal action plans by the end of the meeting. The meeting was the first activity in a joint project of technical assistance by the conveners, aimed at strengthening access to comprehensive post-rape care for survivors of sexual violence. It aimed to sensitize Member States to their obligations under the Maputo Protocol to expand women’s access to emergency contraception (EC) and safe abortion services, and to inspire them to do so by providing information, research evidence, and a platform for discussion. The meeting deliberations fostered a better understanding of opportunities to broaden access to EC and safe abortion for survivors in the region. Discussions on EC in this regard centered on strengthening EC delivery in the clinical context, decentralizing EC services, increasing community awareness, and overcoming policy barriers. Safe abortion discussions focused primarily on legislation, policy, and integrating these services into existing services for sexual violence survivors. Country-specific action plans were developed to address gaps and weaknesses. The regional technical meeting concluded with a discussion of practical steps that participants could take to facilitate legal, policy, and program reform with respect to pregnancy prevention and safe abortion in their respective countries. The steps revolved around three mainly areas, namely: establishing an evidence base to inform action; creating forums for discussing the issues; and drafting action points to carry the momentum from the meeting forward. This paper details the proceedings from this regional technical meeting – proceedings that are of interest to the field of sexual and gender-based violence (and reproductive health, more broadly) as challenges faced by countries in implementing the Maputo Protocol are outlined, and evidence-informed and practice-based strategies for addressing these challenges are provided.