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SCREENING FOR DOMESTIC VIOLENCE: A POLICY AND MANAGEMENT FRAMEWORK FOR THE HEALTH SECTOR

Authors:
SCREENING FOR DOMESTIC VIOLENCE:
A POLICY AND MANAGEMENT FRAMEWORK FOR
THE HEALTH SECTOR
Based on research conducted by the Consortium on Violence
against Women:
Division of Forensic Medicine and Toxicology, University of Cape Town
Health Sector and Gender Violence Project
Institute of Criminology, University of Cape Town
Gender Project, Community Law Centre, University of the Western Cape
Rape Crisis Cape Town
Lorna J. Martin and Tanya Jacobs
Published by the Institute of Criminology
University of Cape Town
Private Bag
Rondebosch
7701
South Africa
© 2003 Institute of Criminology
All rights reserved.
ISBN 0-7992-2217-8
No part of this publication may be reproduced or transmitted in any form or by any means, without prior
permission.
To be cited as:
Martin, LJ. and Jacobs, T. (2003) Screening for Domestic Violence: A Policy and Management Framework for
the Health Sector. Institute of Criminology, University of Cape Town: South Africa.
The views of the authors expressed in this publication do not necessarily reflect those of the Institute of
Criminology or the Open Society Foundation.
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TABLE OF CONTENTS
PART ONE
INTRODUCTION ................................................................................................. 1
PART TWO
A POLICY FRAMEWORK..................................................................................... 4
1. Rationale for the development of a Policy Framework and Management Protocol............4
2. Screening: Intervention through Asking about Abuse ..............................................6
3. Vision.......................................................................................................8
4. Objectives.................................................................................................8
5. Service Delivery ..........................................................................................8
6. Norms ......................................................................................................9
7. Implementation ..........................................................................................9
7.1 Provincial DV Forum...........................................................................9
7.2 Regional DV Forum ............................................................................9
7.3 District DV Forum ............................................................................ 10
8. Monitoring and Evaluation ............................................................................ 11
9. Training.................................................................................................. 11
10. Required Equipment ................................................................................... 12
11. Budget ................................................................................................... 13
11.1 Service Provision............................................................................. 13
11.2 Equipment and Medicine ................................................................... 13
11.3 Training Budget .............................................................................. 13
12. Planning for Sustainability of the Policy............................................................ 13
PART THREE
SCREENING QUESTIONNAIRE FOR A HEALTH FACILITY............................... 14
1. Background.............................................................................................. 14
2. Screening Questions ................................................................................... 14
2.1 Asking Indirectly ............................................................................. 14
2.2 Asking Directly ............................................................................... 14
3. Universal Screening Protocol ......................................................................... 15
PART FOUR
STANDARDISED MANAGEMENT GUIDELINES FOR DISCLOSED
DOMESTIC VIOLENCE ..................................................................................... 16
PART FIVE
DOMESTIC VIOLENCE EXAMINATION FORM .................................................. 18
REFERENCES & ACKNOWLEDGEMENTS......................................................... 30
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STRUCTURE OF THE REPORT
This document is intended to stimulate discussion towards developing and implementing policies
and protocols to address domestic violence as part of a comprehensive health sector response. It is
divided into five parts:
Part One: Introduction
This section introduces the conceptual framework for this research, and provides background to the
development of this policy by the Consortium on Violence Against Women.
Part Two: Policy Framework for Domestic Violence
Part two sketches the context of gender-based violence and highlights the responsibility and
opportunity that the health sector has to respond to this pervasive problem. Screening for domestic
violence is explained and examined, and a proposed vision, objectives, service description and
norms are set out. Requirements for monitoring and evaluation, training, equipment and budget
allocations are set out.
Part Three: Sample Screening Form
This section provides an example of a screening questionnaire to be used within a health facility. It
provides examples of indirect and direct screening questions, as well as a universal screening
protocol.
Part Four: Management Protocol for a Health Facility
Part Four is an example of standardised management guidelines for disclosed domestic violence.
Part Five: Domestic Violence Examination Form
Part Five provides an example of a domestic violence examination form, and includes a report on
the domestic violence examination, consent form, the history of the assault, body charts, special
investigations, treatment plan, safety assessment and plan, referrals, and follow-up.
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DEFINITIONS
The following definitions are used in this report:
Domestic Violence
For the purpose of this Policy the definition of domestic violence will be adopted from the Domestic
Violence Act (Act 116 of 1998). According to this Act, domestic violence means any controlling or
abusive behaviour that harms the health, safety or well being of the applicant or any child in the
care of the applicant and includes but is not limited to-
a) Physical abuse or threat of physical abuse;
b) Sexual abuse or a threat of sexual abuse (any contact which abuses, humiliates,
degrades or otherwise violates sexual integrity);
c) Emotional, verbal and psychological abuse (including insults, name-calling,
ridiculing, degrading conduct, threats to cause emotional pain, jealousy);
d) Economic abuse (including not paying household necessities, bond or rent, selling/
giving away property);
e) Intimidation (meaning making threats or sending threats);
f) Harassment (watching, loitering, making phone calls, letters, packages, emails,
faxes etc.);
g) Stalking (meaning following and accosting);
h) Damage to or destruction of property; or
i) Entry into the applicant’s residence without consent, where the parties do not share
the same residence.
Health Workers
Refers to medical officers and professional nurses, unless otherwise stated.
Health Facility
Refers to all state health facilities from tertiary hospitals to primary health care clinics.
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PART ONE
INTRODUCTION
Gender-based violence is the most pervasive form of abuse and a violation of essential human
rights1, yet it remains an undetected public health priority. Domestic violence, as one of the most
common forms of gender-based violence, is often invisible; either directly when it happens in homes
or indirectly, because criminal justice and societal systems have tended to treat it as a private
matter and one that is normal2.
Research by the Consortium on Violence Against Women3 has confirmed that domestic violence
needs to be addressed as a public sector priority. They suggest that co-ordinated action and
intervention by all sectors, including health, is required to ensure the effective implementation of
the Domestic Violence Act (DVA). However, this research has also shown that the DVA has made
dealing with domestic violence the responsibility of the criminal justice sector. However, health
services often represent the point of first and only contact for women with public sector services.
Abused women often interact with the health care system for routine or emergency care before
turning to criminal justice or domestic violence services, thus placing health workers in a unique
position to identify abuse and intervene. In spite of this, there is relative 'silence' with regard to the
critical role that health has in relation to the DVA, and the essential part this sector should play in
the management of domestic violence.
The Consortium's earlier research has provided a conceptual framework on which to build a
response that maximises the potential of the health sector to assist in addressing domestic violence
in South Africa. Key recommendations from the Consortium’s research include the following:
It must be recognised that the health sector has a critical role to play in the effective
implementation of the Domestic Violence Act.
There is a need for the acknowledgement of domestic violence as a health priority by all
levels of the health sector. Furthermore, there is a need for the recognition of the ethical
obligation to implement a comprehensive health approach to manage the survivors of
domestic violence.
The development of policies and guidelines for all levels of the health sector is essential to
comprehensively address domestic violence. This should include an examination protocol for
the management of women who have experienced abuse.
Advocacy strategies must include dialogue with health sector management in order to
secure their support and commitment to addressing domestic violence.
1 Human Rights Watch (1995)
2 World Health Organisation (2002)
3 The Consortium on Violence Against Women consists of the Gender, Law and Development Project of the
Institute of Criminology at UCT; Rape Crisis Cape Town; the Gender Project of the Community Law Centre at
UWC; the Division of Forensic Medicine and Toxicology at UCT and a health consultant (previously from the
Women’s Health Research Unit at UCT).
2
Capacity building programmes must be implemented in the form of in-service training to
address both professional skills as well as personal attitudes of health sector personnel
towards domestic violence.
The development of local, provincial and national intersectoral partnerships and referral
structures across the health and criminal justice sectors are key to the management of
domestic violence.
Building on this research, a key objective for the Consortium became the development of a
provincial health protocol in relation to domestic violence, to fall within an integrated intersectoral
service delivery framework. This policy is founded on the following principles:
All policy, protocols and services surrounding the use and disclosure of health information,
should respect client autonomy and confidentiality.
A health systems approach is essential to ensure that domestic violence is addressed in a
comprehensive manner.
Management support at provincial level is essential in order to redefine what constitutes an
appropriate response to domestic violence (including attitudinal responses and support
systems).
An appropriate health sector response to domestic violence would include:
Asking about domestic violence i.e. screening;
Comprehensive physical and psychological care for those patients who disclose
abuse;
A safety assessment and safety plan;
The documentation of past and present incidents of abuse, including any physical
injuries;
The provision of information about the patient's rights and the DVA;
Referral to resources
The basic components of a protocol should therefore include:
A definition of domestic violence;
The clarification of any legal requirements for health workers;
Management guidelines;
Intervention strategies;
The procedure for collection of evidence and medical record documentation;
Safety assessment and planning guidelines; and
Referral information.
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A public health approach emphasises the importance of prevention programmes with the co-
ordination of criminal justice and available social support structures.4 Early identification,
comprehensive management, documentation of the abuse and injuries sustained, and appropriate
referral may be one of the most effective strategies to prevent further injury and stem the medical
and psychological consequences of domestic violence.
For this policy to become effective it is essential that there be a recognition within the Provincial
Department of Health that the management of domestic violence requires special training and an
integrated approach. This guiding principle impacts on the consequences for a survivor’s future
safety, mental and physical well being and will improve the standard of criminal justice
interventions in protecting women from their abusive partners.
Any policy on the management of domestic violence must give cognisance to the historical
deficiencies that these survivors have been exposed to at every level of the system from health to
the police and courts. This policy framework recognises that domestic violence is one of the most
pervasive and serious public health problems and that it deserves to be prioritised both in terms of
resource allocation and services available to survivors.
This document has been developed after an analysis of international and local literature and is
based both on the Primary Health Care package for South Africa5 and the Policy and Standardised
Guidelines for the Management of Rape and Sexual Assault Survivors in the Western Cape Province6.
This document is also based on discussions held by an informal Reference Group7 established in 2002
to develop a provincial policy and a management protocol of domestic violence at the health care
facilities in the Western Cape Province after consultation between the Consortium on Violence
Against Women and the Western Cape Department of Health.
This document aims to provide health managers and health workers with a framework for the
introduction of screening for domestic violence as a preventative health care measure within the
Comprehensive Primary Health Care Services of the Department of Health. It also provides a policy
for the management of survivors of domestic violence in relation to patients who disclose. Part 3
(Screening Questionnaire for a Health Facility), Part 4 (Standardised Management Guidelines for
Disclosed Domestic Violence) and Part 5 (Domestic Violence Examination Form) further support this
policy. It is intended that this document be used to begin discussion within the Regions on the
development of a Policy and Management guidelines for Domestic Violence, following the same
successful process employed by the Rape Reference Task Team8.
4 World Health Organisation (1997)
5 Released by the National Department of Health in September 2001.
6 (Notice H 91/2001), drafted by Drs L. J. Martin and L. Denny.
7 This Reference Group consisted of a forensic pathologist, health managers, NGO’s and criminal justice
experts.
8 Constituted in 2000 to develop a management protocol for victims of sexual assault. Co-ordinated by Leana
Olivier of the Directorate of Maternal, Child and Women's Health of the Department of Health, Western Cape.
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PART TWO
A POLICY FRAMEWORK
1. RATIONALE FOR THE DEVELOPMENT OF A POLICY
FRAMEWORK AND A MANAGEMENT PROTOCOL
Violence against women is the world’s most pervasive form of human rights violation. It is endemic
in most societies, but remains unrecognised as a ‘silent’ public health priority.9 Domestic violence
statistics in South Africa are among the highest in the world, with estimations being that 1 in every
4 to 6 women will be beaten by their intimate partner10. There is no indication that the levels of
violence against women in South Africa are decreasing or are likely to do so in the future, despite
our progressive constitution and legislation such as the DVA. Violence against women is still
regarded as culturally acceptable, and in many contexts, is legitimatised11.
The World Health Organisation Report on Violence (2002) shows that violence against women has
been linked to a number of immediate and long-term consequences, including physical injury, and
depression. It affects women's earnings, job performance and parenting abilities. Further negative
health consequences range from serious injury, disability, hypertension, diabetes, anxiety,
headaches, various psychosomatic disorders and even death. The report further notes that in some
countries up to 69% of women report having been physically assaulted and that nearly half of the
women who are murdered are killed by their current or former husband or boyfriend.
Internationally, research has shown that abused women often seek medical attention via emergency
rooms, primary health care settings and mental health facilities, yet abuse is rarely recognised by
health workers12. Increasingly the link between violence against women and the HIV/AIDS pandemic
is being emphasised as research shows that violence against women is both a cause and
consequence of HIV/AIDS. At present there is no national or provincial Department of Health
guideline to address the problem of domestic violence other than the guidelines contained within
the Primary Health Care Package13.
Historically, the management of domestic violence survivors has been sub-optimal on many levels.
Some of the problems have included:
Lack of access to adequate facilities for examination and treatment.
Inadequate knowledge, understanding and/or guidelines for health workers on the
management and health consequences of domestic violence.
Poor quality performance and documentation of the medical/health assessment or
examination resulting in poor quality evidence or no medical evidence presented to the
courts, thus contributing to the low conviction rates.
9 World Health Organisation (1997)
10 NICRO
11 Parenzee, Artz and Moult (2001)
12 World Health Organisation (1997)
13 National Department of Health (2001)
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Secondary traumatisation of survivors by fragmented, dysfunctional systems resulting in
survivors who are either sub-optimally cared for or not cared for at all.
No screening protocols advocated at all in any health care facility.
In addition there are ethical and specific obligations to eliminate ‘discrimination against women’ in
its myriad forms placed on the state (and the Department of Health) by numerous international
agreements. These include:
The United Nations Convention on the Elimination of all Forms of Discrimination Against
Women (CEDAW);
The Beijing Declaration and Platform for Action, a document resulting from the Fourth
World Conference on Women in Beijing, China in September 1995
The United Nations Declaration on the Elimination of Violence Against Women
The Addendum to the SADC Declaration on Gender and Development
Despite the South African government’s ratification of these instruments that condemn violence
against women, and the promulgation of national legislation to combat the problem, there seems to
be no significant change to women’s lives. Women continue to be primarily the victims of violence,
and to be subjected to secondary victimization when they seek assistance from the criminal justice
and health sectors. Reasons for this secondary victimization are numerous and varied and range
from a lack of knowledge and sensitivity on the part of personnel to a scarcity of resources available
implement protective legislation and provide services.
The denial of equality to women, based on the social constructs of gender identity, is the most
pervasive, systematic and deep-rooted violation of human rights. The fostering of human rights
begins in the home, in the neighbourhood, at school, on the farm and in the office. Health care
practitioners are in a position to play an important role in the elimination of violence against
women. They are respected members within the community and are often the first, or only, point
of contact for women who have been abused. Research has furthermore shown that abused women
seek more medical care than non-abused women, and that women who experience violence are
more likely to suffer from any number of serious health problems.
In the consideration of the role of health care practitioners in preventing and eliminating violence
against women, the World Health Organisation espoused the following requirements for health care
practitioners:14
Firstly, do no harm.
Be able to recognise the occurrence of domestic violence and develop appropriate tools and
interventions.
14 World Health Organisation (1997) and Romer, C (1999)
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Be able to share this knowledge with other role players in the social services and criminal
justice systems.
Be aware of possible signs and symptoms of abuse.
Where feasible, ask all routinely about their experiences of domestic violence as part of
history taking.
Provide appropriate care for physical and psychological injuries and document these in the
clients’ medical records.
Refer the client to the relevant social, legal and community resources.
Maintain confidentiality of client information and records.
Health managers and administrators also have a critical role to play in the acknowledgement of the
magnitude and impact of domestic violence and ensuring the appropriate allocation of resources for
policy implementation, capacity building, service provision and research.
2. SCREENING - INTERVENTION THROUGH ASKING ABOUT
ABUSE
The health sector has an important role in secondary and tertiary prevention as early identification
of domestic violence can reduce its consequences and decrease the likelihood of further
victimisation. Internationally early identification of domestic abuse has been emphasised in specific
settings, such as antenatal care, primary health care and mental health services. Many professional
associations and health services use guidelines and protocols to identify women who are abused, a
process referred to as 'screening' for domestic violence.
The following principles need to be adhered to when using screening interventions through asking
women about abuse:
Ensuring that women's safety is paramount.
Do not ask unless privacy and confidentiality can be ensured.
A non-judgemental and supportive attitude is critical.
Training is essential.
Support and referral resources need to be in place.
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In the published literature on domestic violence 'screening' is used in the context of universal
screening and/or selective screening:
Universal screening consists of asking all women in all settings or asking all women in a
specific setting such as antenatal care or PHC, about domestic abuse.
'Selective screening' involves health workers asking women in whom the presenting
problem suggests abuse e.g. unexplained bruises or persistence headaches.
The level of intervention or the screening method employed, will be dependent on the available
human and financial resources at each health care facility, and this decision needs to be made by
the relevant management structures for each district, region and at provincial level. In order for
this policy to be successful and sustainable formal systems must be developed between the
Programme Development, Information Management and Finance Directorates both at a provincial
and regional level.
It is of great importance that the implementation of a policy and protocol for domestic violence is
accompanied by the training of health workers to avoid the problems associated with the
implementation of a domestic violence screening policy. On-going research is also essential to
monitor and evaluate the effectiveness and sustainability of the screening intervention within the
context of broader multi-disciplinary and community based responses. Importantly, the experiences
and perspectives of women who have been screened must form part of the evaluation of the impact
of such interventions. Research15 has shown that screening is a viable practise only if there is a clear
policy, comprehensive training, management support, debriefing and increased links to support
structures.
A general consensus seems to exist that questioning women about domestic violence is a positive
intervention. Gielen et al (2000) note that many women, irrespective of whether they have
experienced domestic violence nor not, value questioning by health workers. A sympathetic and
non-judgmental attitude from health workers can make women feel supported and safe enough to
talk about her experiences. However, issues which need careful attention in the development and
implementation of a screening policy and protocol include:
Who should ask?
Who should be asked?
In what context/setting should the patient be asked?
What training is necessary to equip the healthcare worker to ask?
Screening for domestic violence should not be the end in itself, but rather the beginning of working
partnership with a range of service providers including support organisations, the criminal justice
sector and domestic violence advocates.
15 Vetten, L (2003). This study piloted a screening protocol in six primary health care clinics in Gauteng.
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3. VISION
The adoption of a domestic violence screening protocol will ensure that survivors of domestic
violence are provided with co-ordinated, holistic, expert and humane care, which ensures the
prevention of secondary traumatisation and serves the needs of the individual, the community and
justice. Screening for domestic violence will promote early intervention and will reduce further
victimisation. In order for this to be realised, health care professionals must be given training, as
they are the most important resource to ensure the effective implementation of the protocol.
4. OBJECTIVES
Implementation of the policy and management guidelines will help to achieve the following
objectives:
To provide for ‘screening’ and identification for domestic violence for all women and girls.
To provide an integrated and comprehensive service to survivors of domestic violence that
incorporates the best possible clinical, psychological and medical care available at a
minimum of one health facility per district by the end of 2004.
To provide on-going training, support and supervision of health workers involved in the
management of survivors of domestic violence to ensure a consistently high standard of
care. This will also ensure that the courts are provided with high quality evidence to assist
with the prosecutions and conviction of perpetrators.
To facilitate an intersectoral mechanism at local, and provincial level.
To provide health information to survivors and families which promotes easy of use of
available services in the community and to inform them of their rights.
5. SERVICE DESCRIPTION
The services included in this protocol require co-operation between the health sector, the police
and the Department of Justice. The services will provide:
Counseling and referrals of survivors.
STD prophylaxis and HIV testing, emergency contraception, and care of injuries.
Medico-legal advice and documentation of injuries
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6. NORMS
This protocol is based on the following norms, and are adapted from the Primary Health Care
Package for South Africa:
Every clinic will have established working relationships with the nearest police station,
social welfare office, NGO’s and CBO’s, and hold quarterly visits or meetings with them.
A member of staff of every clinic will have received training in the identification of
domestic and gender-related violence. This training will includes gender sensitivity and
counselling.
7. IMPLEMENTATION
One of the first steps in creating a management system for the screening of survivors of domestic
violence and the management of those survivors who disclose domestic violence would be to
establish domestic violence forums on provincial, regional and district level. These forums could be
incorporated into the already existing network of forums, for example the Rape Forums established
in 2001 following the implementation of the Policy on the Management of Rape Survivors in the
Western Cape Province16.
The broad functions of these forums would be to:
7.1. Provincial DV Forum
Determine and regularly re-view a Provincial Domestic Violence Policy involving all the
relevant stakeholders (e.g. Departments of Justice, SAPS, Social Services, Health and
NGO’s) in order to share information, facilitate co-operation and to avoid duplication.
Lobby for the development of an appropriate intra-departmental central complaint
mechanism to manage complaints of non-compliance to the policy and guidelines.
Provide and update standardised guidelines for medical, nursing, psychological and forensic
management of domestic violence survivors.
Annual evaluation on the implementation of the domestic violence forums, and if
appropriate, lobby for the national implementation thereof.
7.2. Regional DV Form
Liase with the Provincial Domestic Violence Forum.
Assess existing facilities to evaluate whether they are appropriate for the establishment of
domestic violence screening and management services.
16 Western Cape Department of Health (2001)
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Ensure equitable access to all survivors to a domestic violence service at all State health
care facilities.
Monitor the implementation and adaptation of the policy and standardised management
guidelines and ensure that adequate standards of care are maintained.
Identify deficiencies and obstacles in the care of domestic violence survivors and develop
strategies to address these.
Work in collaboration with other initiatives, which focus on the prevention and management
of victims of violence and abuse to co-ordinate service provision.
Keep accurate statistics and demographic data on the service and domestic violence
survivors.
Convene regular meetings (e.g. 3 – 4 monthly) to ensure fluid co-operation and to support
domestic violence service providers at district level.
Co-ordinate regional interdepartmental co-operation.
7.3. District DV Forum
Liase with the Regional domestic violence Forum.
Monitor the provision of a 24-hour health service for domestic violence survivors within all
health facilities in the district.
Monitor accessibility of facilities to the majority of survivors in a district.
Monitor the implementation and adaptation of the policy and standardised guidelines and
ensure that adequate standards of care are maintained.
Ensure that sufficient health workers are trained to provide an appropriate service to
domestic violence survivors.
Ensure that a trained person is available on call for consultation when a survivor is brought
in for management.
Co-ordinate roles and responsibilities of different agencies e.g. SAPS, Justice, Social
Services and NGO’s at district level.
Each facility offering a service to domestic violence survivors should have a designated
room/area for the initial counselling and management of the survivor and his/her support
system after initial disclosure.
Hold regular meetings (e.g. 3 – 4 monthly) to ensure proper implementation of the domestic
violence policy and guidelines and to adapt these to local circumstances.
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8. MONITORING AND EVALUATION
In a Provincial Department of Health the Maternal, Child and Women’s Health Sub-directorate,
supported by the Mental Health, Gender Focus and Reproductive Health Sub-directorates, could be
tasked with the responsibility for driving this process. In order to facilitate, monitor and evaluate
the implementation of this policy the following is needed:
Co-ordination of on-going inter- and intra-departmental collaboration (e.g. Departments of
Justice, SAPS, Social Services, Health, NGO’s, etc.)
Distribution of the policy and standardised guidelines to all the relevant stakeholders.
Monitoring of the correct implementation and regular up-date thereof.
A central departmental liaison for reports regarding non-compliance and/or problems.
Establishment (together with the Directorate Health Information) of a provincial database
for domestic violence statistics to monitor and evaluate on-going provision of services.
Provision of regular feedback to the stakeholders.
Facilitation of appropriate training of health workers.
9. TRAINING
The successful implementation of this policy depends on the skills and competencies of the health
workers performing the service. A training program is an integral part of the development of this
policy in order to equip health workers adequately to perform the necessary screening and
management interventions. It is crucial that the comprehensive health sector response includes
addressing the barriers to health workers asking about abuse, barriers to women disclosing abuse as
well as the broader institutional and structural barriers such as lack of co-ordination with criminal
justice system.
Training as an isolated intervention will be ineffective. It needs to be a component of a sustainable
strategy and programme that ensures structural and administrative change as well as the contribution
to policies and protocols for health services at all levels. A Training Programme on domestic violence
needs to include the following:
The policy and legislative framework.
The extent and nature of domestic violence.
The health and societal impact of domestic violence.
The contents of the Domestic Violence Act (1998).
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The components of a comprehensive health sector response including:
Asking about domestic violence i.e. screening;
Screening for and identifying domestic violence
Safety assessment and safety planning
Medical intervention (physical and psychological care)
Documentation of abuse
Appropriate referral
The health workers' own experience of domestic violence.
Discussion of attitudes, values and societal prejudices and norms.
Working partnerships with other sectors, both government and NGO
Training workshops should include 20-25 participants per workshop and should continue until
sufficient staff have been trained and then offered on an annual basis as refresher courses. These
workshops could be offered in the regions on request via the Gender Focus Coordinator. A
Reference Group should be constituted to develop a training manual and in-service training course.
This manual must be made available to the Human Resource Development Directorate and regional
offices. The regional Human Resource Directorate and Training officers should be responsible for
the facilitation of the continued in-service training of health workers.
10. REQUIRED EQUIPMENT
In order to enable health workers to adequately identify and manage survivors of domestic violence
after initial disclosure the following is necessary at the designated service points:
Private/designated room/area.
Adequate stationary, pre-printed management guidelines (see Part Four for an example),
examination forms (see Part Five for an example) and referral letters.
Access to a telephone and fax machine.
Access to emergency care.
Access to bath/shower and/or toilet facilities.
Posters, pamphlets and information about domestic violence, counselling and human rights.
A list of names, addresses and telephone numbers of the nearest accredited health care
practitioners, police and social workers who would be involved in dealing with domestic
violence cases.
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A list of names and addresses of NGO's, Cobs or other organisations which undertake
appropriate counselling for domestic violence
Reference and educational material.
All relevant guidelines related to women's health issues.
A suitable library of references and journals on sexual offences, domestic and gender
violence
11. BUDGET
11.1. Service provision
As far as possible it is envisaged that existing staff and health facilities should be used. The
designated health care facilities for rape survivors should also be designated for the management of
domestic violence survivors. The same area designated for the examination of rape survivors can be
used for the examination of identified domestic violence survivors.
11.2. Equipment and medicine
The equipment required to perform the examinations should already be available at the designated
health care facilities for rape survivors. The necessary drugs (for example emergency contraceptive
pills) should also be available in these health care facilities. The relevant forms and referral letters
can be ordered from the central stores.
11.3. Training budget
Training should form part of the continued in-service education programme for health workers (see
item 9 above). An initial budget will be necessary for the development of the training manual and
course. Thereafter the trainers will need to be compensated for every training session conducted,
until such time as the Human Resources Directorate for each region can appoint properly skilled and
qualified staff to continue with the in-service training.
12. PLANNING FOR SUSTAINABILITY OF THE POLICY
The following are necessary to ensure the implementation and sustainability of such a program:
Commitment from top management to the implementation of the program.
Allocation of budget to ensure the sustainability of the program.
Support to health workers, especially psychological support.
External evaluation of program after one year of inception.
Incorporation of evaluator's recommendations into provincial policy.
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PART THREE
EXAMPLE OF A SCREENING QUESTIONNAIRE
FOR A HEALTH FACILITY
NOTE: This screening tool should only be used by appropriately trained health
workers and in circumstances of complete confidentiality.
1. BACKGROUND
Universal screening means that asking about abuse is a regular part of health care and that every
woman is asked whether she has ever experienced physical, sexual and/or emotional abuse. This
means that staff must always include a question on domestic violence in the history taking from
women with depression, headaches, stomach pains or a known abusive partner. Staff must include
diplomatic probing of the domestic situation when taking histories of children who fail to thrive,
present with recurrent episodes of trauma or have behavioural problems.
2. SCREENING QUESTIONS
Screening can be done through asking either directly or indirectly. Some examples of screening
questions are as follows:
2.1 Asking indirectly:
? How are things going in your relationship?
? Your symptoms may be related to stress. Do you and your partner tend to fight a lot? Have you
ever been hurt?
? What happens when your partner gets angry?
? Does your partner have any problems with alcohol, drugs or gambling? How does it affect his
behaviour with you and the children?
2.2 Asking directly:
? As you may know, it’s not uncommon these days for a person to have been emotionally,
physically or sexually victimised at some time in their life and this can affect their health many
years later. Has this ever happened to you?
? In this clinic we ask all women patients if they have ever experienced any form of abuse. Have
you ever experienced abuse?
? Sometimes when I see an injury like yours, it’s because someone hit them. Did this happen to
you?
? Has your husband/partner or ex-husband/partner ever hit you or physically hurt you?
? Have you ever been hit, kicked, slapped, pushed or shoved by your boyfriend/husband/partner?
? Has your boyfriend/husband/partner ever forced you to have sex when you did not want to?
? Has a boyfriend/husband/partner ever threatened your life, isolated you from your family or
friends or refused to give you money?
15
3. UNIVERSAL SCREENING PROTOCOL17
17 Adapted from: Task Force on the Health Effects of Woman Abuse, Middlesex-London Health Unit (2000).
Respect her answer
Provide information
on domestic violence
Document response
Repeat that abuse
screening is a regular
part of health care
HAVE YOU EVER EXPERIENCED PHYSICAL, SEXUAL AND/OR EMOTIONAL ABUSE?
Has the abused occurred within last 12 months?
YES
YES
YES
Does the patient still have
contact with the abuser?
Respond in supportive &
non-judgemental way.
Is the patient currently
experiencing abuse?
Does she feel safe now?
Discuss common health consequences
of domestic violence
Assess health status of patient
Document health assessment
Inform patient of legal remedies
Offer referrals & follow-up
Provide comprehensive care as
per standardised management
protocol.
Document all the information in
the Domestic Violence
examination form.
Conduct a safety assessment.
Assist her with safety planning.
Explain the DVA and ask if she
wants to obtain a protection
order.
Ask if she wants to report a case
of assault / rape with the SAPS.
Make appropriate referrals.
Provide comprehensive care as
per standardised management
protocol
Document all the information in
the Domestic Violence
examination form
Conduct a safety assessment
Explain the DVA and ask if she
wants to obtain a protection
order
Ask if she wants to report a case
of assault / rape with the SAPS
Make appropriate referrals
YESNO
NO
NO
NO
16
PART FOUR
EXAMPLE OF STANDARDISED
MANAGEMENT GUIDELINES FOR DISCLOSED
DOMESTIC VIOLENCE
1. All patients who disclose domestic violence must be assessed as soon as possible using the
attached domestic violence examination form.
2. When a person presenting to a clinic discloses domestic abuse or alleges to have been
abused or assaulted the allegation is assumed to be true and the victim is made to feel
confident they are believed and are treated correctly and with dignity.
3. Under no circumstances should any patient be turned away to seek help from another
facility.
4. The Domestic Violence Examination Form constitutes the confidential medical record of
the patient. It may however be subpoenaed as a court document if the court deems it
necessary. It is essential to record all information and findings accurately, legibly and to
remember that the original document could become part of a court record.
5. Complete the Domestic Violence Examination Form. A checklist for documentation is
noted below:
Document the exact words used by the patient.
Do not ask the patient about abuse in the presence of children as they pose a risk to
confidentiality.
Document the identity of the offender and his relationship to the patient.
Record the history of abuse – the presenting complaint of recent abuse, and all
incidents of past abuse.
Document all symptoms experienced and injuries sustained for present and past abuse.
Document all injuries by recording the measurements thereof with a ruler, the exact
anatomic location, the nature of injury, the age and any healing that has occurred. Use
the body charts for recording a sketch.
If possible state that the injury is consistent with the patient’s account.
Take photographs if resources permit.
Ensure that all medical records are stored safely, preferably in the Superintendent’s
office.
6. Remember to label each page with the patient’s name and folder number.
7. Establish whether the patient has reported the matter to the police. Explain to her the
advantages and disadvantages of reporting the incident mindful of the patient’s risk of
danger of doing so at this instant. Respect the patient’s choice of not to report.
17
8. If she chooses to report the case to the police, then the health worker must phone the
police station in the area in which the domestic violence occurred and ask for a police
officer to come to the health facility to take a statement from the patient.
9. If the survivor declines to report the domestic violence to the police or to undergo a full
physical assessment, this choice should be respected and no undue pressure exerted on her.
10. A J88 form must be filled in for all cases where the patient has reported the incident to the
police and in instances where the patient indicates that she will lay a charge of assault or
where she will seek relief in terms of the Domestic Violence Act. The J88 form will be used
for the court record in the first instance, and must be given to the SAPS after examination.
PLEASE NOTE: Detailed notes made on the J88 form may obviate the need to testify in
court at a later date. However, if court testimony is necessary, the detailed notes on the
domestic violence screening form will serve as an aide d’ memoir to compiling an additional
affidavit or testifying from, to complement your J88 notes, that will provide the court with
good medical evidence.
11. All domestic violence survivors are to be interviewed by the appropriate health professional
in a confidential manner in a private room for appropriate examination and counselling. It
is advisable that the spouse/partner or children are not present during the interview.
12. Routine clerking notes of the patient must be kept in the patient’s folder, especially special
investigations performed, treatment given and follow up appointment dates.
13. Domestic violence survivors should be advised to have an HIV test.
14. Domestic violence survivors should be given the option of going for counselling to:
Social worker
Trained counsellor (region specific)
Private therapist, e.g. psychologist
Domestic violence support services or other local services
15. The survivor and family should be given an updated list of local resources, if it has been
established by the health professional that is safe for the patient to do this.
16. The survivor and family should receive literature on domestic violence to take home and
read later, if it has been established by the health professional that is safe for the patient
to do this.
17. Domestic violence survivors should be referred to the next level of care when their needs
fall beyond the scope or competence of clinic staff.
18. All patients, community and children attending clinic are educated and informed on abuse.
19. As part of community outreach clinic staff establish links with relevant organisations already
operating and providing services to victims and survivors of abuse.
20. If you are subpoenaed to give medical evidence in a domestic violence case, you are
strongly advised to consult with the prosecutor and other medico-legal experts before giving
testimony in court.
18
PART FIVE
EXAMPLE OF A DOMESTIC VIOLENCE
EXAMINATION FORM
NOTE: This examination form should only be used by appropriately trained health
workers and in circumstances of complete confidentiality.
1. Ensure the examination is conducted in a safe and secure place.
2. Allow any support persons that the survivor requests to be present during the examination.
3. Document the exact words used by the patient.
4. Do not ask the patient about abuse in the presence of children as they pose a risk to
confidentiality.
5. Document the identity of the offender and his relationship to the patient.
6. Record the history of abuse – the presenting complaint of recent abuse, and all incidents of
past abuse.
7. Document all symptoms experienced and injuries sustained for present and past abuse.
8. Document all injuries by recording the measurements thereof with a ruler, the exact
anatomic location, the nature of injury, the age and any healing that has occurred. Use the
body charts for recording a sketch.
9. If possible state that the injury is consistent with the patient’s account.
10. Take photographs if resources permit.
11. Ensure that all medical records are stored safely, preferably in the Superintendent’s office.
19
Patient Name: Folder No.
REPORT ON DOMESTIC VIOLENCE EXAMINATION
PATIENT INFORMATION:
Name:
Folder No:
Date of Examination: / / Time of Examination: h
Marital Status:
Children (number & ages) Whereabouts:
Patient accompanied by:
EXAMINATION PERFORMED BY:
(Print name, phone number and/or beep number)
1. Medical Officer: Contact Tel. No:
2. Registered Nurse: Contact Tel. No:
ADDITIONAL INFORMATION
Has a criminal charge been laid? Yes No
If yes, what charge was laid?
SAPS Station: MAS No:
If no, does the patient intend laying a charge/applying for a protection order in terms of the Domestic
Violence Act?
Yes
No
Unsure
20
Patient Name: Folder No.
CONSENT:
Authorisation for collection of evidence and release of Information:
I hereby authorise CHC/Hospital
(name of clinic or hospital)
And
(name of health worker)
Please tick:
To document all injuries and collect any blood, urine, tissue or any other specimen needed.
To take photographs of my injuries.
To supply copies of relevant medical reports including laboratory reports to the South
African Police if re
q
uested.
I recognise that the Domestic Violence Examination Form is solely to direct the appropriate clinical and
forensic management of me and to record any injuries I may have evidence of. This information is
confidential and will remain with my confidential medical records.
I understand that the medical and forensic information handed over to the South African Police Service
will be contained in the J88 form.
Person examined:
(Print Name) (Signature)
Witness:
(Print Name) (Signature)
Parent/guardian:
(Print Name) (Signature)
Date: / /
Name of Institution:
Official Stamp:
21
Patient Name: Folder No.
Name: Age: Sex:
HISTORY OF ASSAULT
1. Most recent assault:
Location of incident:
Date of Incident: Time: h
Relationship of assailant to the patient:
Nature of the abuse:
PHYSICAL EMOTIONAL SEXUAL FINANCIAL
Hitting Name Calling Unwanted Touching Withholding Money
Kicking Yelling/Shouting Infidelity Taking Money
Use of a weapon Restricting contact with
Family/Friends
STI's Controlling All Financial
D
ec
i
s
i
o
n
s
Pushing Threats Forced Intercourse Other
Choking Controlling her activities Other
Burns Other
Other
Patient’s description of assault (use exact words as far as possible. Describe frequency & severity of
assault).
22
Patient Name: Folder No.
2. Other episodes of assault:
Describe frequency & severity of past abuse, using direct quotes from the patient. Describe mechanism,
location and extent of injury and/or other symptoms/conditions.)
3. Emotional Status:
4. Medical Information:
Is the patient pregnant? Yes No
Date of Last Menstruation:
Other Medical Concerns (e.g. insomnia, pain, headaches, signs of stress or depression):
5. Examination:
General Appearance:
Height: Weight: Body Build:
Description of Injuries
23
Patient Name: Folder No.
6. Body Charts:
24
Patient Name: Folder No.
25
Patient Name: Folder No.
26
Patient Name: Folder No.
27
Patient Name: Folder No.
SPECIAL INVESTIGATIONS:
RESULTS
HIV Testing: Yes No Positive Negative
STI Screening: Yes No
Pregnancy Test: Yes No Positive Negative
X-rays: Yes No
TREATMENT PLAN/GIVEN:
Injuries:
Emergency Contraception:
STI's:
PEP:
SAFETY ASSESSMENT:
A woman’s safety is very important, and her danger is the highest if she lives with the abuser or continues
to see him at regular intervals. Health workers need to be especially aware of this, specifically if she
verbalises that she feels unsafe. Health workers are not experts in this area and referral to SAPS or an
appropriate agency may be the best course of action at this time. If this is not acceptable to the patient,
then the health worker can perform a preliminary safety check, strongly advising the patient to consider
the short and long-term outcomes.
A safety assessment must be done for all patients who disclose domestic violence. The following needs to
be established:
Has the violence increased? Yes No
Does the perpetrator use alcohol and drugs? Yes No
Has the perpetrator threatened to kill her? Yes No
Are there weapons at home/does the perpetrator have access to weapons? Yes No
Is the client afraid to go home? Yes No
Has she thought about killing herself? Yes No
28
Patient Name: Folder No.
Record answers to the following questions. The answers to the questions can be assigned a value for risk
assessment. Assign a value for the answers as follows: No = 0 Yes = 1
Add up the total to provide a risk rating: 0 - 3 «Caution
4 - 7 «High Risk
8 - 11 «Severe Risk
Has he threatened you with physical violence? Yes No
Has he threatened the children with physical violence? Yes No
Is there a firearm in the house? Yes No
Has he threatened to kill you? Yes No
Has he threatened to kill the children? Yes No
Does the patient think he is capable of killing her? Yes No
Were alcohol and/or drugs consumed prior to the last incident of abuse? Yes No
Was SAPS intervention necessary? Yes No
Is he presently in the home? Yes No
Has the abuse escalated in either frequency or severity? Yes No
Have you ever received medical treatment for injuries sustained as a result of
abuse? Yes No
TOTAL RATING
SAFETY PLAN:
A short-term safety plan is a set of strategies that can assist the immediate safety of your patient and
help her to be prepared for further violence. A safety plan must be discussed with all patients who
disclose domestic violence. Knowing the level of danger will help the health worker and client to think
through what the options are. An initial safety plan worked out at the health facility will probably only
deal with the immediate situation. There is no formula for safety planning, but the health worker can help
the client think and plan the following:
? What will you do when you leave the health facility?
? Will you seek help from SAPS and/or courts?
? How will you ensure your children’s safety?
? Where can you go if you need to leave home?
? Who can you trust to tell about the domestic violence?
? Where can you leave money, clothing, copies of documents and valuables if necessary?
? Will you accept a list of important telephone numbers referrals to help with longer-term
safety planning?
29
Patient Name: Folder No.
REFERRAL:
Have you referred your patient to an appropriate agency? Yes No
OPTION 1:
OPTION 2:
OPTION 3:
INFORMATION:
Is it safe to give your patient written literature? Yes No
If not how have you conveyed the information to your patient?
Have you given your patient appropriate information with regard to domestic
violence, referral agencies, safety plans, and shelters?
Yes No
FOLLOW UP:
Date for follow up appointment with patient in your outpatient clinic or at
the designated health care facility where/when you will be in attendance
Was your patient satisfied with the referrals you made for her? Yes No
Signature:
Print Name:
Qualifications:
Health Facility:
Date:
30
REFERENCES
Family Violence Prevention Fund (2000) Preventing Domestic Violence: Clinical Guidelines on Routine
Screening.(www.fvpf.org)
Garcia-Moreno C (2002) 'Dilemmas and Opportunities for an Appropriate Health Service Response to
Violence Against Women' in The Lancet Vol. 359 Issue 9316
Gielen AC, O’Campo PJ, Campbell JC, Schollenberger J, Woods AB, Jones AS, Dienemann JA, Kub J and
Wynne EC (2000) 'Women’s Opinons about Domestic Violence Screening and Mandatory Reporting' in
American Journal of Preventative Medicine Vol. 19 Issue 4
Heise L, Ellsberg M and Gottemoeller M (1999) Ending Violence Against Women Population Reports. Series
L, No 11. Baltimore, Johns Hopkins University School of Public Health, Population Information Program.
Human Rights Watch (1995) Violence against Women in South Africa. New York: Human Rights Watch.
Parenzee, P., Artz, L. and Moult, K. (2001) Monitoring the Implementation of the Domestic Violence Act:
First Research Report Institute of Criminology, University of Cape Town
Romer C (1999) Violence and Health Report of the WHO/FIGO Pre-congress workshop on violence against
women. (WHO/HSC/PVI/99.2) World Health Organisation: Geneva
UNAIDS (2001) Gender and HIV factsheet accessed at http://www.unaids.org/fact_sheets/index.html
United Nations Population Fund (2001) A practical approach to gender-based violence. A programme guide
for health providers and managers written by L Stevens. United Nations Population Fund: Geneva
Vetten L (2003) Screening women for domestic violence: a viable practise in South Africa? Presentation at
the 2nd South African Gender-based violence and Health Conference 7-9 May 2003, Gauteng
World Health Organisation (2002) World Report on violence and health edited by Etienne Krug. World
Health Organisation: Geneva
World Health Organisation (1997): Violence Against Women: A Priority Health Issue. World Health
Organisation: Geneva
POLICY DOCUMENTS
National Department of Health (2001) A Comprehensive Primary Health Care Service Package for South
Africa
Western Cape Department of Health (2001) Survivors of Rape and Sexual Assault: Policy and Standardised
Management Guidelines (Notice H91/2001) drafted by Drs LJ Martin and L Denny.
LEGISLATION
Domestic Violence Act, 116 of 1998.
31
THE DOMESTIC VIOLENCE EXAMINATION FORM HAS BEEN ADAPTED
FROM THE FOLLOWING MATERIALS:
Metro Women Abuse Council (Toronto), Ontario Hospital Association. Best Practice Guidelines For Health
Care Providers Working With Women Who Have Been Abused. Ontario Hospital Association #401, Canada.
Osattin A, Short LM. Intimate partner violence and sexual assault: A guide to training materials and
programs for health care providers. Atlanta. Centre for Disease Control and Prevention, National Centre
for Injury Prevention and Control, 1998.
Pollack S and Mackay L. (2001) Report of The Women’s Safety Project Pilot Study: Evaluation of Batteries’
Programs. Woman Abuse Council of Toronto: Canada.
Task Force on the Health Effects of Woman Abuse, Middlesex-London Health Unit. (2000) Task Force on
the Health Effects of Woman Abuse – Final Report. London, Ontario, Canada.
Western Cape Department of Health (2001) Survivors of Rape and Sexual Assault: Policy and Standardised
Management Guidelines (Notice H91/2001) drafted by Drs LJ Martin and L Denny.
Woman Abuse Council of Toronto (2001) High Risk Response Pilot Project: An integrated model for
creating safety, Final Report. Woman Abuse Council of Toronto: Canada.
Woman Abuse Council of Toronto (Accountability Committee) (2000) Creating Safety: Tools to Promote a
Safe and Co-ordinated Response to Women’s Safety. WACT, Canada.
World Health Organisation. (2003 forthcoming) Guidelines for Medico-Legal Care for Victims of Sexual
Violence - Sexual Violence Examination Record. World Health Organisation: Geneva
ACKNOWLEDGEMENTS
The authors would like to thank the following people for their valuable time, dedication and contribution
to the development of this report.
Members of the Consortium on Violence Against Women: Kelley Moult, Dee Smythe, Lillian Artz,
Heléne Combrinck, Penny Parenzee, Sam Waterhouse, Raygaanah Barday, and Nolitha Mazwayi for
information, comments and ongoing support.
And finally,
Without the ongoing support, assistance and encouragement from the Open Society Foundation, and in
particular, Cheryl Frank and Renald Morris, this research would not have been realised.
... To address the need for a health sector response to DV and to work towards overcoming the obstacles discussed above, Martin and Jacobs (2003) developed a strategic framework for introducing DV screening and holistic care of DV victims into state-run HCFs. Based on local and international research and existing Department of Health policies, and after lengthy debate between medical practitioners and criminal justice specialists to strike a balance between the two objectives of medical and psycho-social care and evidence collection, the instruments were carefully tailored to the South African context. ...
... The recent recommendations by the Portfolio Committee on WYCPD have merely reinvigorated a neglected area of legal and health reform. The necessary research has already been conducted and a screening tool and treatment guidelines have been developed (Martin and Jacobs, 2003), evaluated and amended (Joyner, 2009). This is therefore an important opportunity for those working within the nexus of 'health and justice' to advocate for the amendment of the DVA, for the DVA to make provision for relevant health and psycho-social services for DV victims Á similar to those provided for sexual offence survivors under the Sexual Offences Act Á and to include positive duties on HCPs to properly screen and treat DV patients. ...
... the Committee did not explicitly recommend screening by HCPs, despite civil society having advocated for this in their submissions over the past 15 years There are, of course, some things to consider. For instance, Martin and Jacobs (2003) advocated for universal screening but conceded that this may not always be possible in the resource-poor South African context. It will have to be decided at provincial and regional levels whether HCFs have the resources for universal screening, or if they should rather practice selective screening in cases where patients display symptoms of abuse. ...
Article
Domestic violence (DV) is one of the most pervasive forms of violence in South Africa with numerous physical and psychological consequences that have severe and enduring impacts on health. This takes a significant toll on women, their families and the health care system. Local and international literature suggests that DV is one of the most common reasons for women to present at health care facilities, placing health care practitioners in a unique position to identify abuse and intervene. As widespread as it is, DV is not a specifically prioritised public health concern and thus suffers from vastly inadequate resource allocation. The Domestic Violence Act, No 116 of 1998, was the first and only South African legislative attempt to recognise DV victims’ rights to seek immediate medical assistance. It did not, however, impose any positive legal duties on health care practitioners to inquire about, screen for or holistically treat DV-related injuries and other health-related consequences of DV or make referrals. The Act only implies that health care practitioners have a duty to attend to DV cases. International codes delineate duties for health care practitioners in providing care for women in abusive relationships, and South Africa has detailed medico-legal protocols for the examination and treatment of survivors of sexual offences. It is therefore curious that a similar treatment protocol does not exist for DV. This Article reviews the literature on the health consequences of DV and the need for screening, and recounts the historical attempts of civil society in South Africa to impose legal duties on the state to assist DV victims who present to health care facilities. We argue that it is time that Parliament review the provisions of the Domestic Violence Act to include legal duties on health care practitioners to properly address the health consequences of DV.
... 30-1). The implied guidelines for the design and development of a pre-hospital medical protocol for DV victims for the ECP are cogently articulated in Screening for Domestic Violence: A Policy and Management Framework for the Health Sector (Martin & Jacobs, 2003). The HPCSA may enable individuals under its jurisdiction to do more, but it is the above framework that has most relevance for the EMS implementation. ...
... This has the potential to deliberately leave victims of abuse in the abusive home -oblivious to their level of risk, if not screened for DV. In the context of emergency care, the screening guidelines by Martin and Jacobs (2003) have not been surpassed by Joyner's Intimate Partner Violence Model (Joyner & Mash, 2012a). The forensic focus of the former aligns well with the ECP forensic role. ...
... The WHO recommends the development of a comprehensive health sector response (World Health Organization 2006;. The document Screening for Domestic Violence: A Policy and Management Framework for the Health Sector (Martin & Jacobs, 2003) has influenced the development of emergency care guidelines but does not suffice. The EMS response to DV should be congruent with that of the health sector and should include routine screening (asking about DV routinely), clinical case finding, comprehensive physical and psychological care for those patients who disclose abuse, a safety assessment and safety plan, the documentation of past and present incidents of abuse, the provision of information about patients' rights and the DV Act and referral to resources (Martin & Jacobs, 2003). ...
Article
Full-text available
Domestic violence (DV) is common globally. In South Africa, emergency care providers (ECPs) lack a clear policy framework and the necessary training to identify DV and intervene when it is encountered. We investigate the knowledge, attitudes and beliefs of ECPs towards DV, and identify factors affecting early identification and its appropriate management in South Africa. A survey of 154/266 registered operational ECPs of different qualification levels and employed by a provincial emergency medical service was conducted. Each participant voluntarily and anonymously self-completed a customised questionnaire. Some 75 (49%) ECPs had an acceptable understanding of DV, although those with higher level qualifications were significantly more knowledgeable (p = 0.017). Most (147,97%) identified that alcohol and drugs were the main cause of DV. A few ECPs (15, 10%) reported having had experience of safety-focused and appropriate gender-sensitive handling of DV victims. The ECPs’ qualification levels were not significantly associated with their knowledge of the legislation about DV or with whether they had referred victims of DV. Only 49 (22%) ECPs reported having occasionally referred victims. By their own admission these ECPs expressed inadequate ability to assess and manage DV cases in current ECP practices. There was poor understanding of the extent, nature, detection and referral of DV cases by ECPs relative to their incidence. This may be due to incorrect beliefs or myths about DV, inadequate training and problematic emergency system design. Our findings support the need for a comprehensive emergency care response to guide and standardise DV management with better understanding of gender-based violence in order for the emergency medical service to play a more preventive and holistic role in its responses.
... [5,6] IPV harms sexual and reproductive health, causing higher risks of contracting HIV and other sexually transmitted infections (STIs). [1,7] Significantly, victims are less likely to be tested for HIV or to seek medical care, fearing either violence or abandonment if their partner learns that they are HIV-positive. [7] Abused women have higher rates of unintended pregnancies, abortions, miscarriages, preterm deliveries and still births. ...
... emergency rooms), or more subtle, such as repeated visits to primary care centres, mental health services, general practice or other disciplines, where IPV is unlikely to be identified. [1] Further examples of how IPV can present are set out below. ...
Article
Full-text available
Intimate partner violence (IPV) is a silent public health epidemic in South Africa (SA). Interpersonal violence in SA is the second highest burden of disease after HIV/AIDS, and for women 62% of the former is ascribed to IPV. SA, therefore, has the highest reported intimate femicide rate in the world. IPV has far-reaching consequences, stretching across generations. The cost to the economy and burden on health services are considerable. IPV presents in many ways, cutting across all medical disciplines. Therefore, all medical professionals should be conversant with this issue. This article provides essential, practical steps required for identifying and managing IPV, applicable to any setting. These steps are summarised as six Rs: Realise that abuse is happening (be aware of cues); Recognise and acknowledge the patient’s concerns; Relevant clinical assessment; Risk assessment; cRisis plan; and Refer as needed for medical, social, psychological and/or legal assistance. © 2016, South African Medical Association. All rights reserved.
... Barriers to data quality are cited throughout the literature and include the following: lack of organizational support; characteristics of the violence-related data elements; design of the ambulance run report form; and paramedic knowledge, attitudes, and behaviours regarding data collection (Boergerhoff, Gerberich, Anderson, Kochevar, & Waller, 1999). Finally, health sector screening is a priority (Martin & Jacobs, 2003) as it facilitates access to care. A computerised system for screening emergency room (ER) patients for intimate-partner violence did not endanger victims either in the hospital or after they went home. ...
... DV needs to be recognised as a health priority by all levels of the health sector and the development of policies and guidelines for all levels is essential to comprehensively address DV. This should include an examination protocol for the management of women who have experienced abuse (Martin & Jacobs, 2003). In response, the HPCSA has approved screening guidelines in EC. ...
Article
Full-text available
The aim of this policy brief is to provide an evidence-informed answer to the question: 'What is the role and scope of pre-hospital emergency care providers to domestic violence (DV) intervention as a form of gender-based violence prevention?' The answer is intended to determine the theoretical and clinical best practice to inform the emergency care community and policy development by critically appraising the evidence that considers the responsiveness of Emergency Medical Services to the health needs of DV victims. Evidence-informed Decision Making methods are employed. The evidence appraised was based on electronic searches using the Cape Peninsula University of Technology database. Research and non-research publications were considered with publication dates mostly from 1999 to 2011. Upon screening 164 articles for content relevance, 53 were critically appraised against predetermined criteria for relevance of the evidence, robust nature of the evidence and presence of bias. A thematic/
... In addition to the successful policies and laws mandating or encouraging DV screening by HCPs coming out of developing countries, SA would not be starting from scratch. The screening tools already developed and tested by Martin and Jacobs 46 and Joyner and Mash 47 are ready for adoption, and the International Planned Parenthood Federation manual would be a useful guide for HCPs and health care facility managers. South Africa arguably has one of the most welldeveloped and entrenched medico-legal systems in Africa, as evidenced by services available to survivors of sexual offences and is, therefore, well equipped to learn from other countries' successes and best practices and to introduce routine screening for DV. ...
Article
Full-text available
Background: Since 2013, approximately 4400 women have been murdered by their partners in South Africa. This is five times higher than the per capita global average. Domestic violence is known to be cyclical, endemic and frequently involves multiple victims. It also becomes progressively more dangerous over time and may lead to fatalities. In 2012, the Health Professions Council of South Africa released a domestic violence protocol for emergency service providers. This protocol, or screening guidelines, includes assessing future risk to domestic violence, providing physical and psychosocial care, documentation of evidence of abuse and informing patients of their rights and the services available to them. The extent to which these guidelines have been circulated and implemented, particularly by general health care practitioners (HCPs), is unknown. Aim: We review international treaties to which South Africa is a signatory, as well as national legislation and policies that reinforce the right to care for victims of domestic violence, to delineate the implication of these laws and policies for HCPs. Method: We reviewed literature and analysed national and international legislation and policies. Results: The ‘norms’ contained in existing guidelines and currently practiced in an ad hoc manner are not only compatible with existing statutory duties of HCPs but are in fact a natural extension of them. Conclusion: Proactive interventions such as the use of guidelines for working with victims of domestic violence enable suspected cases of domestic violence to be systematically identified, appropriately managed, properly referred, and should be adopted by all South African HCPs.
... Although the DVA does not go as far as providing a legal framework that fully integrates these practices in the delivery of services to victims, it does provide some scope for this to take place. Ongoing monitoring research into the implementation of the DVA has been instrumental in providing researchers with a range of possibilities for more comprehensive services (see Artz 2003; Martin & Jacobs 2003; Mathews & Abrahams 2001; Parenzee, Artz & Moult 2001; Parenzee & Smythe 2003). ...
Chapter
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This chapter takes a critical look at the developments and challenges in research, policy and practice in relation to violence against women since 00. The chapter draws out intersections between criminal justice and health sector responses over a range of issues, including screening for domestic violence, documentation of injuries following sexual assault, and the collection data on intimate femicide. Throughout the writers emphasise the need for integrated medical and legal responses. In addition to presenting a sample of legislative developments relating to sexual offences, the extent to which the South African judiciary has enforced the constitutional right to freedom from violence through relevant case law is examined. This analysis includes the impact of empirical research and expert testimony from medico-legal, sociological and mental health practitioners on judicial decision-making. In reinforcing violence against women as a serious public health issue, the writers traverse the division between law and health in an attempt to underscore the critical links between the law, public policy and service provision to victims of gender-based violence.
... However, the health professionals neither respond to the disclosures of the women in IPV appropriately nor ask them questions directly on IPV. This happens despite a number of research studies that reveal that women in IPV want to be asked by health professionals about IPV (Martin & Jacobs, 2003;Taket, Beringer, Irvine, & Garfield, 2004;WHO, 2005). Hague and Mullender (2006) argue that if services addressing IPV are to continue to develop, and effectively meet the needs of women in IPV, then the views of those using them should be taken heed of and acted upon. ...
Article
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Intimate partner violence (IPV) against women is a global human rights abuse and public health issue. Few studies have documented the actual voices of women discussing their experiences on IPV. South Africa is one of the countries with the highest rates of IPV, however little is known about the experiences of women on IPV. This happens despite health professionals namely professional nurses being in a strategic position to listen to the women's views on IPV. Hence the purpose of this study was to explore the experiences of women on IPV in a public hospital in Tshwane, South Africa. A qualitative design was used. An in-depth interview with semi-structured questions for probing was used for data collection. Biographic data and field notes were collected. Ten interviews were conducted based on data saturation. Interviews were transcribed verbatim and analysed by means of content analysis and coding. Ethical clearance was obtained. The ethical and safety issues in this study were ensured by using the WHO guidelines on gender-based research and the ethical principles in accordance with the Belmont report. Measures to ensure trustworthiness were adhered to. Emerging themes were: 1) Health effects of IPV 2) Cultural influences of IPV 3) Resilience 4) Benefits of the interview. These findings highlight the severity of physical, psychological, emotional and sexual violence borne by older women. The findings will help health professionals and policymakers to respond appropriately to the needs of women in IPV.
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Domestic violence is a complex healthcare burden for South Africa and the world over. In 2013, the Health Professions Council of South Africa endorsed a domestic violence-screening guideline for Emergency Care providers. It is unknown if any accredited Emergency Care training facility has implemented these guidelines so as to improve the prehospital emergency care management of domestic violence victims. The probable absence of its wide-scale implementation suggests the prehospital identification and management of domestic violence victims continues to be at the discretion of the attending emergency care provider. To bridge the gap between theory, policy, and practice of domestic violence response, simulation training is proposed as a method of sensitising emergency care students and providers to manage cases which they may encounter in the “real world”. This study aimed to position emergency care students and providers as advocates for the interests of adult domestic violence victims’ during the (simulated or real) emergency care interaction so as to improve the emergency care provider responsiveness to victims of domestic violence. The primary research question was: How does the scripting of evidence-informed simulations of domestic violence cases enhance practitioner responsiveness and patient safety among prehospital emergency care students? The paradigm and methodology for this qualitative study was social constructivism and grounded theory respectively. A literature review preceded pre-simulation focus group discussions, participant observation during patient simulations, and post-simulation focus group discussions. Each data collection method helped strengthen and focus the proceeding data collection, honing in on the emerging theory. Through the process of constant comparative analysis, four categories of understanding emerged: ‘The need for Emergency Care provider role definition in DV intervention’; ‘Impediments to prehospital Domestic violence response’; ‘Emergency Care provider empathy during domestic violence response’ and ‘Conducting effective domestic violence-based simulations’. The finding is that: scripting of evidence-informed simulations can improve the responsivity to domestic violence cases by highlighting the theoretical gaps in knowledge, and help participants to meaningfully engage with the relevant content (laws, regulations, screening protocol for abuse, and referral agencies). Furthermore, the scripted simulations made vivid the need for an empathic and patient-centred approach in clinical practice (in addition to the commonly used skill-orientated approach). Scripting of simulations with the use of peer-based training may be an effective method of achieving improved responsivity to domestic violence. Traditional EMS training with mannequins may not be as effective for this purpose as students require a level of feedback and fidelity through which they can convey their empathy and history-taking skills. To make future domestic violence simulations effective they need to have clear and achievable outcomes. The study findings are of relevance to health professions educators, emergency care education centres, the professional regulator and civil society organisations involved in domestic violence crisis intervention.
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Article
The purpose of this paper is to describe women's opinions and policy preferences concerning domestic violence screening and mandatory reporting. This case-control study included 202 abused women and 240 randomly selected non-abused women recruited from a large metropolitan health maintenance organization who were interviewed by telephone. Of these women, 46.6% had a college degree, 53.4% were white, and 60% had a household income of $50,000 or more. Forty-eight percent of the sample agreed that health care providers should routinely screen all women, with abused women 1.5 times more likely than non-abused women to support this policy. For mandatory reporting, 48% preferred that it be the woman's decision to report abuse to the police. Women thought it would be easier for abused women to get help with routine screening (86%) and mandatory reporting (73%), although concerns were raised about increased risk of abuse with both screening (43%) and reporting (52%) policies. Two thirds of the sample thought women would be less likely to tell their health care providers about abuse under a mandatory reporting policy. Interventions offered in managed care settings that would be well received, according to the women in this study, include counseling services, shelters, and confidential hotlines. Women expressed fears and concerns about negative consequences of routine screening and, even more so, for mandatory reporting. Domestic violence policies and protocols need to address the safety, autonomy, and confidentiality issues that concern women.
Article
This article is an overview of the role of health services in secondary and tertiary prevention of intimate partner violence. In it, I review the evidence, which comes mostly from developed countries, on the effectiveness and limitations of in-service training programmes to identify and care for women who have experienced intimate partner violence. I also discuss recent initiatives in developing countries to integrate concerns on gender-based violence into health-care services at different levels, some of the dilemmas and challenges posed by the current approaches to intimate partner violence, and recommendations for future interventions.
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