Most women welcome
inquiries, but doctors and nurses rarely ask
can be physical, sexual, or psychological. Physical
and sexual violence by an intimate partner are
common problems, affecting 20-50% of women at
some stage in life in most populations surveyed
globally.1 Between 3% and 50% of women have
experienced it in the past year.1 Domestic violence
has a profound impact on the physical and mental
health of those who experience it. As well as
injuries, it is associated with an increased
risk of a range of physical and mental health
problems and is an important cause of mortality
from injuries and suicide.
Review of international
literature on risk of domestic violence shows
that although it is greatest in relationships
and communities where the use of violence in
many situations is normative, notably when witnessed
in childhood, it is substantially a product
of gender inequality and the lesser status of
women compared with men in society. Except for
poverty, few social and demographic characteristics
define risk groups. Poverty increases vulnerability
through increasing relationship conflict, reducing
women's economic and educational power, and
reducing the ability of men to live in a manner
that they regard as successful. Violence is
used frequently to resolve a crisis of male
identity. Domestic violence is often associated
with heavy alcohol drinking.3 Research suggests
that the different factors have an additive
that alter the prevalence of any of these risk
factors may alter the prevalence of domestic
violence, few programmes that seek primarily
to reduce, for example, poverty or consumption
of alcohol evaluate the impact on the prevalence
of domestic violence. A notable exception was
the Grameen Bank project in Bangladesh, where
ethnographic evaluation suggested that women
participating in the microcredit programme were
protected to some extent against domestic violence
by having a more public social role.
that domestic violence can be prevented in populations
in developing countries that have not been specifically
identified as affected through life skills type
programmes that address gender issues and include
relationship skills. A review of qualitative
evaluations and experiences using the Stepping
Stones, a training package to promote sexual
and reproductive health in various communities
in Africa and Asia, found a reduction in conflict
and violence in sexual relationships to be a
major impact in all communities studied.
on domestic violence focus on women and men
who have been identified as abused or abusing.
Evaluation of initiatives has been sorely lacking.
The only review of programmes to prevent domestic
violence found 34 projects that had been evaluated,
two thirds of which were in the criminal justice
system. In many countries interventions focus
on legal redress and secondary prevention through
protection orders, shelters, counselling services,
specialised police units and courts, and mandatory
arrest laws. Although many women find these
helpful, evidence of their effectiveness in
preventing domestic violence is limited. Treatment
programmes for abusers are similarly found in
many countries but, unless compulsory, they
are plagued by very high drop out rates. Again
the evidence for their effectiveness is weak.
The two papers
in this issue confirm previous research that
shows that domestic violence is a common underlying
problem in clinical practice (pp 271, 274).
Bradley et al show strong associations with
anxiety and depression.10 The papers also confirm
research findings from the United States that
show that most women welcome inquiries, but
doctors and nurses rarely ask about it. One
obvious explanation for this is that they are
not trained to do so and are uncertain what
they can do. Gender and health issues, including
domestic violence, feature little in undergraduate
and postgraduate medical training programmes
In many parts
of the world training programmes on domestic
violence for staff in service focus on training
staff to ask direct questions about abuse, assess
safety, provide a simple supportive message
such as no woman deserves to be beaten, and
provide information on legal rights and where
to go for further support or counselling. However,
the evidence that these activities benefit women
is still limited. Research is hampered by the
fact that many programmes have failed to achieve
the desired change in clinical practice, although
this is more likely to occur if programmes are
supported by other changes in the working environment
such as having inquiry protocols, posters reminding
staff, or prompts in the case notes. Other key
problems with training have been that programmes
are too short (often one to three hours long),
neglect the personal experiences of domestic
violence of the staff that may influence their
approach to the issue, fail to provide an adequate
understanding of this complex behavioural problem,
and fail to set it in a broader gender context.
Advances in effectiveness of efforts to introduce
routine inquiry into clinical practice are needed
before large scale evaluation is possible.
the lack of evidence of effectiveness of interventions
may pose a barrier to action, and Richardson
et al argue that indeed it should be. However
the question of what is effectiveness in this
context has not been resolved and it is premature
to suggest that lack of evidence equates to
ineffectiveness. Bradley et al present an important
argument that inquiry about domestic violence
should be regarded as a way of "uncovering
and reframing a hidden stigma" and that
inquiry is in itself beneficial, even if no
action immediately follows from it.
The impact of
domestic violence on health has been well established
and the rationale for prioritising prevention,
including addressing it in clinical practice,
is strong. A need exists for much more research
on screening outcomes, acceptability, effectiveness,
and effective interventions in changing clinical
practice. Fresh medical graduates need to be
equipped with an understanding of gender issues
in society, the impact of gender inequality
on health, and of the dynamics of the problem
of domestic violence so that they are better
placed to respond to the issue, understand the
possibilities and limitations of their role,
and adjust their practice to emerging scientific
evidence. Socioeconomic inequalities have become
a mainstream part of medical teachingit is now
time for the medical establishment to embrace
the issue of gender.
and Health Group, Medical Research Council,
Private Bag X385, Pretoria 000, South Africa
- Heise L, Ellsberg M, Gottemoeller
M. Ending violence against women. Baltimore:
Center for Communication Programs, John
Hopkins School of Public Health, 1999.
- Campbell J. Health consequences
of intimate partner violence. Lancet (in
- Jewkes R Intimate partner
violence: causation and primary prevention.
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- Schuler SR, Hashemi SM,
Riley AP, Akhter S. Credit programmes, patriarchy
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Oxford: Strategies for Hope, 1995.
- Gordon G, Welbourn A.
Stepping stones and men. Washington,DC:
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- Chalk R, King PA. Violence
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programs. Washington, DC: National Academy
- National Institute of
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in family violence: research findings and
policy implications. Washington, DC: US
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- Edleson JL. Intervention
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- Richardson J, Coid J,
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- Garcia-Moreno C. What is
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