Violence against women, particularly intimate partner violence, is a serious public health concern. Lorna Rothery spoke with Britta Baer, Regional Advisor on Violence Prevention at the Pan American Health Organization (PAHO), about the risks and effects of violence, along with strategies for prevention and protection
How can crises, whether they are economic, related to climate change, or humanitarian, affect the prevalence of violence against women and girls?
It is estimated that approximately one in three women in the Americas, as well as globally, have experienced physical or sexual violence at some point in their lives. A significant portion of this violence is classified as intimate partner violence, affecting about one in four women.
In any emergency situation, the risk of violence tends to increase. Violence does not have a single cause; rather, it is influenced by a range of factors, and these factors operate at multiple levels: individual, peer, community, and societal. Individual factors interact with peer influences, social norms, communication patterns, economic conditions, and social inclusion. Such interactions underscore the importance of gender equality and demonstrate how various factors across different levels can either increase or decrease a person’s risk of experiencing violence.
PAHO recently published a report examining the experiences of Indigenous and Afro-descendant women regarding violence. This report was important as it addressed data gaps concerning these groups and involved collaboration with representatives from Indigenous and Afro-descendant communities to engage them in analyzing the topic.
In summary, any woman can be at risk of experiencing violence due to the complex interplay of various factors. In specific situations, such as emergencies, the risk factors tend to increase. For instance, during the COVID-19 pandemic, stress, increased alcohol abuse, reduced mobility, and limited access to support networks contributed to triggers for violence.
Have countries made progress in data collection since COVID?
I believe it has increased over time, generally; this is not a new topic for the region. Data has always played a central role in our understanding and response to violence. However, the issue is broader than just the data itself. Despite the significant challenges we face concerning violence and its health consequences, it’s crucial to remember that violence is preventable.
When discussing prevention, we must recognize that the health system serves as the first line of response. This is an encouraging aspect of our region. In 2015, the countries of the Region of the Americas were the first to come together on this important issue and to identify actions we could take to address it.
There are many effective solutions that countries can implement to tackle violence against women. The process begins with the initial interaction of women who may be survivors or who may not have experienced violence themselves. Evidence shows that all women find it beneficial to discuss violence within health services. Raising the topic as a health issue in a confidential healthcare setting is crucial, which is why strengthening the response of health services is so important.
Many individuals do not come forward after experiencing violence due to fear of stigma, shame, and other barriers. Frontline health workers play a critical role in this context. They can create a safe space for conversation and significantly influence how a survivor’s journey unfolds when they disclose their experiences. If the first person they approach responds with compassion – using phrases like “Thank you for sharing this with me,” “This is not your fault,” and “It’s good that you’ve reached out” – it can validate the survivor’s feelings and encourage them to seek further help.
This support not only provides vital information but also guides individuals through the next steps, which may involve accessing additional healthcare services due to the numerous health consequences of violence. These steps could also require collaboration with other services, such as protection, legal aid, police, social services, or housing.
If this initial interaction is a positive experience, individuals are more likely to seek help again. Conversely, a negative experience may deter them from reaching out in the future. It’s essential to recognize that violence often escalates over time. By equipping the health system to identify and intervene early, particularly with at-risk groups, we can either prevent violence from occurring or reduce its severity, ultimately avoiding the need for more extreme interventions.
What are some of the mental health impacts and socioeconomic consequences of intimate partner violence?
The consequences of violence against women are significant and affect nearly every aspect of health. These include injuries, fatalities, sexual and reproductive health issues, chronic health problems, and mental health concerns. The impacts of such violence are extensive and far-reaching.
Experiencing violence significantly affects mental health in various ways. Research indicates that it increases the likelihood of developing mental health conditions, including depression. Notably, survivors of intimate partner violence globally are 4.5 times more likely to attempt suicide. These consequences are indeed severe.
When considering the health impacts of violence, it is crucial to recognize that they are not limited to immediate effects; there are also short-term, medium-term, and long-term implications, especially concerning mental health. Violence can have lifelong effects on a woman’s mental wellbeing.
Preventing these short-term impacts is critical, but it is also essential to address medium- and long-term effects on mental health. Fortunately, many of these impacts can be mitigated or prevented. Therefore, from a mental health perspective, it is vital to engage early with at-risk groups and provide them with support. This approach can help prevent negative outcomes related to mental health and other health issues within the healthcare system.
Socioeconomic costs of violence include financial burdens at the macro level, the burden on general practitioners (GPs), and individual factors such as education, productivity, career progression, and social inclusion.
It is crucial to focus on prevention. Research shows that when children witness violence in the home, especially between their parents, it can profoundly impact their health and behavior. This exposure increases the risk that these children will later become involved in violence, either perpetrating or experiencing violence themselves. Therefore, we have a crucial role in preventing violence, not only for the immediate wellbeing of individual survivors but also in breaking the cycle for future generations. This serves as a compelling reason to recognize violence as a public health issue.
We should consider various risk and protective factors within education, social, and economic systems. Our approach must be a collaborative effort that spans different sectors and levels of governance. PAHO engages extensively with the RESPECT framework, a comprehensive multi-agency and multi-sector approach to preventing violence against women and girls. RESPECT comprises seven strategies – each represented by a letter in the acronym – illustrating the social-ecological model. It incorporates health services as a critical entry point while addressing a wide range of educational, social norm change, and economic development interventions.
PAHO collaborates with UN Women, the World Bank, and numerous other partners because we recognize that we cannot tackle these issues alone. This spirit of inter-agency collaboration is also reflected at the country level, where we observe multi-sectoral strategies for preventing violence against women. These strategies often include contributions from various ministries, including health, education, social affairs, economics, finance, and culture.
There is truly no limit to the number of actors we can engage in this effort – the more, the better. It is essential to involve different levels of governance and civil society to create a comprehensive and effective response.
What are the key actions and future goals for how PAHO aims to strengthen health administrative data related to violence?
Our primary role is to collaborate with the health sector and various countries, focusing on strengthening health system responses, as the initial interaction with survivors is crucial. We advocate for something called ‘LIVES’ (Listen, Inquire, Validate, Enhance Safety, Support), which stands for first-line support; how we respond to disclosures of violence within the health system is vital.
It’s encouraging to see the progress made across countries in this region on this issue. Many countries have established health system protocols emphasizing first-line support and identifying essential health services in response to violence. This is the starting point of our work. Much of PAHO’s effort involves assisting ministries of health and other stakeholders in aligning their health system protocols with the continuously growing evidence base. This field is evolving, and we are gaining better data and insights into what truly works.
We work closely with ministries of health to ensure that their guidance, protocols, policies, manuals, and tools align with this evidence base, as this is the crucial first step. When well-defined health system protocols are in place, it becomes clearer what actions health system personnel need to take. The next step involves training; we ensure that every health worker understands what to do, when to do it, and how to do it.
Our focus is on enhancing support for primary care and frontline providers, who can significantly impact the situation. Recently, we launched a new online course in English and Spanish, developed in collaboration with about 200 health sector representatives across Latin America and the Caribbean. This course content not only aligns with the evidence base but also addresses the specific needs of health workers. Offering this online course is advantageous because it provides a free and accessible resource for individuals.
Historically, the issue of violence against women has often been overlooked in the training of doctors, nurses, and other frontline healthcare staff.
Training health workers is crucial because, without proper guidance, they lack the necessary tools to do this critical role. These workers are on the front line of response efforts. Regardless of how well-designed a protocol is, it cannot be effectively implemented without a trained health worker. Therefore, much of our work focuses on training and support for the health sector. This may involve offering online courses, assisting the Minister of Health with in-country training, collaborating with universities on pre-service training, or providing clinical tools, manuals, job aids, and posters. These simple resources can remind health workers of the essential steps they need to take.
During my travels, I have encountered numerous health workers who are eager to help and understand the gravity of the issues at hand. Thus, providing them with simple tools is a high priority to ensure they can fulfil their important roles.
Another topic I am passionate about is the role of administrative data. A key strength of addressing violence through a health systems approach is its focus on evidence and data. The health system possesses a wealth of information on this subject, and the potential uses for this information are vast. Accurately documenting each patient interaction is vital for any health issue, including violence. Good health records allow for quality care across multiple interactions with the health system.
When a survivor has a complete medical history, it ensures that they don’t have to start from scratch with each visit. This continuity is essential for providing quality care. For survivors of violence, it is especially important to minimize the number of times they have to recount their experiences. Reducing the frequency with which survivors must share their stories is one of the most significant improvements we can make within the health system. Unfortunately, survivors often find themselves having to seek help multiple times, resulting in repeated retelling of their traumatic experiences.
Every time survivors share their story, the process becomes increasingly challenging for them. We can mitigate this impact through effective health documentation. When we properly document a case during the first interaction, we create a record that eliminates the need to ask the same questions repeatedly. This not only alleviates trauma for the survivor but also significantly enhances their perception of the quality of care they receive.
Proper documentation is essential for a thorough response and serves as a crucial resource when the survivor seeks justice. By keeping detailed records from the first contact with healthcare services, we can gather important evidence for future legal proceedings. Initial documentation can provide key evidence and timelines if the survivor wishes to take subsequent legal actions.
From the perspective of the health system, accurate administrative data is essential. During a meeting held last August, focal points from various Ministries of Health across the region emphasized the need for robust engagement in data collection related to violence against women. For these officials to assess the implementation of protocols and enhance the quality of care across health services, they require data. Without this information, it is difficult to understand what is happening and where improvements are necessary.
Administrative data is crucial in enabling the Ministry of Health and other health system managers to monitor the quality of care. Once they have the ability to monitor, they can implement improvements. This was the impetus behind the publication of a toolkit by PAHO at the end of last year, which focuses on documenting cases of violence against women and girls and recording the health sector response. The toolkit includes guidance for health workers on documentation, information for policymakers, and potential quality indicators.
This initiative was driven by requests from Member States and is grounded in existing practices across the region. We examined the cases from countries like Brazil, Mexico, Peru, Honduras, Antigua and Barbuda, and Trinidad and Tobago to strengthen existing mechanisms and support the sharing of information across nations. The importance of this data cannot be overstated – it is unique to health services and vital for understanding the use of services and the quality of response.
DATA/STATS
- Globally, the most common form of men’s violence against women is intimate partner violence. [1]
- 1 in 3 women and girls aged 15–49 in the Americas have experienced physical and/or sexual violence by a partner or non-partner sexual violence. [2]
- Nearly 1 in 4 adult women (23%) and approximately 1 in 7 men (14%) in the US report having experienced severe physical violence from an intimate partner in their lifetime. [3]
- Violence against women often stems from power imbalances and structural inequalities between men and women. [4]
- Interventions involving women and men of different ages and backgrounds and use multiple approaches as part of the same intervention can lead to measurable reductions in violence. [5]
