Screening women for intimate partner violence in healthcare settings: abridged Cochrane systematic review and meta-analysis
BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2913 (Published 12 May 2014) Cite this as: BMJ 2014;348:g2913All rapid responses
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To the Editor: O’Doherty and colleagues have conducted an interesting study [1] and concluded that there is insufficient evidence to support intimate partner violence (IPV) screening in healthcare settings. They made this conclusion because there was inadequate evidence to show that IPV screening increases effective referral to supportive agencies, or improve the quality of life of survivors. Several respondents did not agree with O’Doherty’s findings [2-4]. We are presenting evidence from a resource constrained developing country that might support IPV screening.
The Family Planning Association (FPA) is a leading sexual and reproductive health (SRH) facility in Sri Lanka that also has a counseling center. From 01 January 2013 onward, FPA started screening its clients for domestic violence (including IPV), and referred the identified survivors to family counselors; counselors provided both individual and couple counselling to the survivors. We conducted a preliminary study between 01 January and 31 May 2013 at the Headquarter SRH clinic of FPA to evaluate the feasibility of this screening and counseling process. We also evaluated its short term effectiveness to improve the well being of domestic violence (DV) survivors. We analyzed data using SPSS version 17 statistical software (Chicago, USA).
In total, 1710 clients visited the Headquarter SRH clinic during the first 3 months of the study-from January to March 2013. We asked from 257 (15%) on DV; we could not ask about DV when client density was high, number of medical officers was less, and clients were rushed for time. Of those asked (n=257), 81(31.5%) disclosed DV. All who disclosed DV were referred to the counselors using referral slips. Of them, 36(44.5%) met a counselor; 29 (80.6%) of that 36 presented for at least one follow-up counseling session. We assessed the psychological well being of those 29 survivors at the baseline and at two months follow-up, using four Likert scales: 1) the happiness scale ranged from 1=very sad to 7=very happy, 2) the self-esteem scale ranged from 1=very low to 7=very high, 3) the perceived safety scale ranged from 1=not safe at all to 7=very safe, and 4) the perceived stress scale ranged from 1= no stress at all to 7= very stressed. After the two-month follow-up counseling, we also interviewed 6 survivors (20%) randomly to assess their psychological well being; we compared these qualitative results with the scale scores and confirmed an association.
Of the 36 DV survivors who met counselors, 49% reported physical violence, 3% reported sexual violence and all reported psychological violence. In 86% of the time, the abuser was the husband or the boyfriend. The survivors’ perceived happiness was significantly higher after the counselling (Median (Mdn) = 5.0) than before counselling (Mdn = 2.0 ), z= -4.7, p<0.001. The perceived self esteem was also significantly higher after counselling (Mdn = 5.0) than before counselling (Mdn = 2.0), z = -4.7, p<0.001. After counselling, survivors felt safer than they were before (Mdn = 7 before and after, z = -2.82, p<0.001). Further, they felt less stressed after counselling than before counseling (Mdn = 2.0 vs 6.0, z = -4. 8, p<0.001).
Hence, our study showed that two months after the initial counselling, the DV survivors were happier, less stressed, had better self esteem, and felt more safer compared to the baseline. Yet, the study has some limitations and the results should be interpreted with caution. We could only screen 15% of the total clients. Our follow-up period was short. Our sample size was small and we did not have a control group. Yet, our findings indicate that DV screening might benefit the survivors if it was combined with individual and couple counselling. Specially in developing countries where stigma and economic dependence prevent survivors from seeking external assistance, the DV screening at health settings might be a way to identify and assist those women who suffer silently. Studies should investigate further on this highly discussed issue and provide better conclusions.
References
1. O'Doherty LJ, Taft A, Hegarty K, Ramsay J, Davidson LL, Feder G. Screening women for intimate partner violence in healthcare settings: abridged Cochrane systematic review and meta-analysis. BMJ. 2014 May 12;348:g2913. doi: 10.1136/bmj.g2913.
2. Kress-Dunn PK. Re: Screening women for intimate partner violence in healthcare settings: abridged Cochrane systematic review and meta-analysis. BMJ 2014; 348: g2913. Retrived on 09 September 2014 from http://www.bmj.com/content/348/bmj.g2913/rr/700807
3. Saripanidis S. Re: Screening women for intimate partner violence in healthcare settings: abridged Cochrane systematic review and meta-analysis. BMJ 2014; 348: g2913. Retrived on 09 September 2014 from http://www.bmj.com/content/348/bmj.g2913/rr/699632
4. Timmis S. Re: Screening women for intimate partner violence in healthcare settings: abridged Cochrane systematic review and meta-analysis. BMJ 2014; 348: g2913. Retrived on 09 September 2014 from http://www.bmj.com/content/348/bmj.g2913/rr/699482
Competing interests: No competing interests
Once again the problem of domestic violence is presented with a single direct victim: women.(1)
A recent publication in The Lancet on the global prevalence of intimate partner homicide (2) finds that overall 13·5% of homicides were committed by an intimate partner, and this proportion was six times higher for female homicides than for male homicides.
Moreover, in a paper published in 2005,(3) results shown that the gender disparity in injuries from domestic violence is less than originally portrayed by feminist theory and that males appear to report their own victimization less than females do and to not view female violence against them as a crime.
It should be noted that the new guidance of de NICE on the subjet,(4) states that at least 1.2 million women and 784,000 men aged 16 to 59 in England and Wales experienced domestic abuse in 2010/11 – 7.4% of women and 4.8% of men and at least 29.9% of women and 17.0% of men in England and Wales have, at some point, experienced it.
Therefore Women and men can experience this type of violence in heterosexual and same-sex relationships.
Obviously It is not only a gender problem.
A recent paper (5) states that comparing male and female victims across lethal and non-lethal intimate partner violence (IPV) can provide a better understanding of these incidents and assist policy makers in developing more tailored victim services and prevention programs.
Intimate partner violence should not be a problem of men against women or vice versa: should be just a problem among people, among human beings.
1 O'Doherty LJ, Taft A, Hegarty K, Ramsay J, Davidson LL, Feder G. Screening women for intimate partner violence in healthcare settings: abridged Cochrane systematic review and meta-analysis. BMJ. 2014 May 12;348:g2913. doi: 10.1136/bmj.g2913.
2 Stöckl H, Devries K, Rotstein A, Abrahams N, Campbell J, Watts C, Moreno CG. The global prevalence of intimate partner homicide: a systematic review. Lancet. 2013 Sep 7;382(9895):859-65. doi: 10.1016/S0140-6736(13)61030-2.
3 Dutton DG Nicholls TL. The gender paradigm in domestic violence research and theory: Part 1—The conflict of theory and data. Aggression and Violent Behavior 10 (2005) 680–714
4 National Institute for Health and Care Excellence. Domestic violence and abuse: how health services, social care and the organisations they work with can respond effectively. NICE public health guidance 50. Feb 2014. www.nice.org.uk.
5 Fatal and Non-Fatal Intimate Partner Violence: What Separates the Men From the Women for Victimizations Reported to Police. Homicide Studies 2014 18: 196-220. doi: 10.1177/1088767912471341
Competing interests: No competing interests
As a survivor of what was termed "severe" domestic violence, I am dismayed by the outcome of this study. I did tell our family doctor, who seemed rattled by this information and provided no help at all. I believe that handing a woman a card with a shelter and/or counseling phone number should be done whenever intimate partner violence is suspected. It may take her years, but having that number to call when it's safe, and knowing there are places she can turn for help, can go a long way. Training of all healthcare providers should be mandatory. And re: the cover photo, please bear in mind that injuries may be in other places, not just the cliched black eye. The perpetrators know how to hide the effects of their violence, in places such as the hand or on the back of the head (both of which I suffered). The first looks innocuous, and second is invisible. But they are signs of violence nonetheless.
Competing interests: No competing interests
O’Doherty et al’s meta-analysis of the effectiveness of 11 studies in screening women for intimate partner violence highlights the gender bias in the reporting of and research into intimate partner violence. Domestic violence is widely presented as and is perceived to be a women’s health problem and O’Doherty makes no reference to men who are victims of intimate partner violence.
The most reliable estimate of the extent of domestic violence in England and Wales indicates that 40% of all domestic violence is suffered by men (800,000 assaults on men in 2013 compared with 1.2 million on women) (1). The number of assaults on men is likely to be an underestimate because of the reluctance of men who are victims of intimate partner violence to seek help (2) in part due to the taboo nature of violence against men and the fear that men who are victims of intimate partner violence have of being rejected, humiliated or ridiculed by professionals (3). Even when men who are victims of intimate partner violence do contact the police, violent women are more likely to avoid arrest than violent men (4) and violent women are often viewed by law enforcement officials and the criminal justice system as victims, rather than as the perpetrators of violence against men (5). There are a lack of support services available for men who are victims of intimate partner violence and health care professionals often don’t have the training to deal with or appropriately support men who are victims of intimate partner violence (3).
Intimate partner violence is a serious public health problem which affects men as well as women. Systematically privileging the experience of women whilst ignoring the experience of men in the public discourse of intimate partner violence colludes with cultural norms which treat women’s suffering as more important and more serious than men’s. This type of misandry obscures the equivalence of all human suffering irrespective of the gender of the victim.
References
1 Crime statistics, Focus on Violent Crime and Sexual Offences 2012/13 (Crime Survey for England and Wales 2011/12) Office for National Statistics
2 Kumar A (2012) Domestic Violence against Men in India: A Perspective Journal of Human Behaviour in the Social Environment 22(3): 290-296
3 Barber CF (2008) Domestic violence against men Nursing Standard 22(51): 35-39
4 Felson RB and Pare P-P (2007) Does the Criminal Justice System Treat Domestic Violence and Sexual Assault Offenders Leniently? Justice Quarterly 24(3):435-459
5 Kingsnorth RF and MacIntosh RC (2007) Intimate Partner Violence: The Role of Suspect Gender in Prosecutorial Decision-Making Justice Quarterly 24(3):460-495
Dr Shaun Bhattacherjee
Consultant Forensic Psychiatrist
Broadmoor Hospital
Berkshire
Competing interests: No competing interests
Dear Editors,
In my Country, a recent investigation revealed that one in three women has been a victim of physical abuse, last year alone!
Husbands and boyfriends make up the majority of the attackers.
Screening is counterproductive, when such high prevalence rates exist.
Better focus on quick and effective interventions for victims.
Reference
http://www.ekathimerini.com/4dcgi/_w_articles_wsite1_1_01/11/2013_525870
Competing interests: Dr Stavros Saripanidis is an active voluntary member of a non-profit organization that fights for women's rights.
We are grateful for the thoughtful responses to our abridged Cochrane review of universal screening for intimate partner violence (IPV). And, as Decker and colleagues point out, this is only the most recent contribution to a long debate in the field of IPV research and policy.
What we have in common with our critics is a strong commitment to improving the health care response to IPV. Where we differ is over their underlying assumption that universal screening in health care settings is the most effective method of identifying and assisting women experiencing abuse. There is no evidence for that assumption. The direct tests of the effectiveness of screening vs. usual care that are included in our review show that identification is only modestly increased, but this is also seen in domestic violence interventions in health care settings using case-finding or clinical enquiry.(1)(2) Moreover, attempts to implement IPV screening in the absence of robust evidence of greater effectiveness than other identification methods, may actually reinforce health care professional reluctance to screen and reduce their engagement with IPV. Surveys of health care professionals, mostly in the United States, consistently show that the majority are not in favour of IPV screening, although they do recognize that IPV is an important health care issue.(3)
Turning to specific points raised in the rapid responses, we are sorry that Decker and colleagues are disappointed with the scope of review. We have answered a valid and important question: based on current trial evidence, is IPV screening with an initial response and potential referral from health care professionals (without a further post-screening intervention) effective? This question is important since screening with referral is the most common policy recommendation and most screening programmes introduced in health care settings do not include further training, system changes or interventions to assist the survivor. The findings of our review directly challenge the effectiveness of those policies. We can also reassure Decker and colleagues that our findings have not dissuaded us, nor should they dissuade other researchers “from pursuing a research-informed health care system response to IPV.” We do not think, based on the trial evidence to date, including the most recent US study,(4) that screening should be an intrinsic part of the overall health care response. We do not argue that screening is wrong per se, but that its effectiveness should be compared with other identification methods, that it may be better targeted and not universal (e.g. in ante-natal or mental health settings), and that any method of IPV identification need to be integrated into training programmes and system changes that are integral to safe and effective health care responses to IPV.
Ahmed highlights the high prevalence and co-morbidities of IPV in patients using mental health services and the additional difficulties these patients face in disclosing abuse. Yet this is an insufficient justification for screening, which she acknowledges: “more research to be done in this area prior to screening being safely introduced”. Asking about abuse should be part of good clinical practice when taking a history from a patient with mental health problems, due to the strong association between mental ill health and IPV. That is not the same as a universal screening programme.
In contrast to Whitehouse, we do not think that our findings will “discourage health professionals from identifying and signposting”, as long as they receive regular and sustained training and resources on identification and appropriate responses. We are definitely not saying that clinicians should sit back and wait for disclosures of IPV.
Singh and colleagues discuss the challenges of responding to IPV in the Indian health care system, and remind us that family or domestic violence is broader than IPV. But they also believe that the high prevalence and barriers to disclosure “warrant[s] screening of intimate partner violence in the hospital and health care settings”. This brings us back to a central plank of our argument: high prevalence is an insufficient justification for a screening programme. An effective health care response to IPV does require asking patients about abuse, but mandating the implementation of universal screening without effective interventions to support patients currently experiencing, or with a past history, of abuse is neither warranted nor a good use of resources. IPV programmes in health care settings can legitimately use a range of identification methods.
We agree with Fabre that case finding or clinical enquiry triggered by a wide range of presenting symptoms or conditions is necessary, but would not use the term “screening” to describe that method of identification, as it gets confused with universal screening. We are also convinced by the evidence for training and for referral pathways for further support to survivors of IPV.
We commend Timmis for her project in an accident and emergency department which suggests that IPV identification rates do not increase after implementation of screening until staff receive additional training. As we have emphasized above, training in case finding or clinical enquiry also increases identification rates.
The fact that US health care policy, including recommendations from such distinguished organisations as the Institute of Medicine and US Preventive Task Force, recommend screening for IPV continues to surprise us in the absence of evidence for its effectiveness. This policy conflicts with the recently issued evidence-based World Health Organisation guidelines.(5) In addition the UK National Institute for Health and Clinical Excellence guidelines (6) and the Canadian Task Force on Preventive Health Care appraisal of the US guidance (7) does not support universal screening for IPV.
We believe that the imposition of an IPV screening policy in some countries and the debate over the best method of identifying survivors of IPV have distracted researchers and advocates from developing and testing interventions post-disclosure of IPV and the system level changes in health care settings that may benefit abused women and their families.
Lorna J O’Doherty
University of Melbourne
Australia
Angela Taft
La Trobe University
Australia
Kelsey Hegarty
University of Melbourne
Australia
Jean Ramsay
Barts and The London School of Medicine and Dentistry
United Kingdom
Leslie L Davidson
Columbia University
United States
Gene Feder
University of Bristol
United Kingdom
(1) Feder G, Davies RA, Baird K, Dunne D, Eldridge S, Griffiths C et al. Identification and Referral to Improve Safety (IRIS) of women experiencing domestic violence with a primary care training and support programme: a cluster randomised controlled trial. Lancet 2011; 378(9805):1788-1795.
(2) Taft AJ, Small R, Hegarty KL, Watson LF, Gold L, Lumley JA. Mothers' AdvocateS In the Community (MOSAIC)--non-professional mentor support to reduce intimate partner violence and depression in mothers: a cluster randomised trial in primary care. BMC Public Health 2011; 11:178.
(3) Feder G, Ramsay J, Dunne D, Rose M, Arsene C, Norman R et al. What is the prevalence of partner violence against women and its impact on health? How far does screening women for domestic (partner) violence in different health-care settings meet criteria for a screening programme? Systematic reviews of nine UK National Screening Committee criteria. 13 ed. 2009. 17-27.
(4) Klevens J, Kee R, Trick W, Garcia D, Angulo FR, Jones R et al. Effect of screening for partner violence on women's quality of life: a randomized controlled trial. JAMA 2012; 308(7):681-689.
(5) World Health Organization. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. WHO, 2013. http://apps.who.int/iris/bitstream/10665/85240/1/9789241548595_eng.pdf
(6) National Institute for Health and Care Excellence. Domestic violence and abuse: how health services, social care and the organisations they work with can respond effectively. NICE, 2014. http://www.nice.org.uk/guidance/index.jsp?action=byID&o=14384
(7) Canadian Task Force on Preventive Health Care. Domestic Abuse 2013 Critical Appraisal Report. Canadian Task Force on Preventive Health Care, 2013. http://canadiantaskforce.ca/perch/resources/domestic-abuse.pdf
Competing interests: Gene Feder chaired and Kelsey Hegarty was part of the guideline development group of the WHO Responding to intimate partner violence and sexual violence against women guidelines; Gene Feder chaired the programme development group of the UK NICE domestic violence and abuse guidelines
The recently published meta-analysis by O’Doherty et al. examining the effectiveness of screening for intimate partner violence in healthcare settings concluded that universal screening is not warranted . I have recently conducted a screening project in a London A&E department examining the impact of a diagnostic algorithm for intimate partner violence made available in the notes of women presenting with physical injury during a four-week sampling period . Training sessions to heighten awareness among relevant A&E staff were an important component of the project. The diagnostic rate for intimate partner violence among injured women during the study was not significantly different compared with a historical control period (7.8% versus 6.8%). However, within the study period a sharp increase in the rate of diagnosis from 5% in the first 2 weeks to 11% in the last 2 weeks followed a series of supplementary training sessions. My findings are not definitive but suggest that screening programmes within A&E departments – often the first port of call for victims of intimate partner violence – can be successful if there is sufficient awareness among all relevant staff for effective programme delivery. Intimate partner violence is hugely under-reported and it is too early to dismiss screening programmes based on the findings of O’Doherty et al.
Competing interests: No competing interests
We agree with O'Doherty et al (BMJ 2014;348:g2913) that universal screening in healthcare settings is not warranted for intimate partner violence (IPV). However, we are facing a serious problem. One in three women globally suffer physical or sexual abuse from a partner. 38% of all murdered women are murdered by their partners. At the World Health Assembly in Geneva this year, the Medical Women’s International Association (MWIA), along with three other organisations representing doctors and medical students, presented a statement supporting the WHO report addressing the global challenge of violence against women and girls (1).
What is needed is targeted screening by health professionals in primary care, dental surgeries, antenatal, gynaecological, paediatric and mental health clinics, as well as in Accident and Emergency departments. Clinical conditions associated with IPV include depression, anxiety, pelvic pain, chronic unexplained pain, fibromyalgia, and headaches. Sensitive questioning, careful documentation and signposting to effective services if required are appropriate first steps. Ignorance among health professionals of the correct pathways of referral is a major problem and must be addressed urgently. The National Institute for Health and Care Excellence (NICE), in their recent report (2), emphasised the importance of training of health professionals, and responding effectively to domestic violence. Establishing a practical system to deal with this problem at a national (and international) level is an urgent challenge.
(Dr) Clarissa Fabre
Medical Women’s International Association representative to WHO
Buxted Medical Centre, East Sussex
(1) World Health Organization. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. WHO, 2013.
(2) National Institute for Health and Care Excellence. Domestic violence and abuse: how health services, social care and the organisations they work with can respond effectively. NICE, 2014.
Competing interests: No competing interests
Intimate partner violence (IPV) is a rapidly emerging public health problem in India. The problem is far beyond the scope of domestic violence. According to “The Protection of women from domestic violence Act, 2005 (India)(DVA), domestic violence is considered to be any act of physical, sexual, verbal or emotional, economic abuse, or the threat of such abuse, inflicted against the woman by a person who is legally married, or in family or domestic relation.” Under the Act “aggrieved person” means any woman who is, or has been, in a domestic relationship with the respondent and who alleges to have been subjected to any act of domestic violence by the respondent (the man). The term “domestic relationship” means a relationship between two persons who live or have at any point of time, lived together in a shared household, when they are related by consanguinity, marriage, or through a relationship in the nature of marriage, adoption, or are family members living together as a joint family” (1).
The DVA nowhere mentions clearly about the emerging phenomenon of live- in- relationship, seen commonly in the Indian metropolis where man and woman live together as family members without marriage. The confusion has been partly removed the Supreme Court’s interpretation which states that “nature of marriage” could not be used by women of all sorts of live-in relationships to seek benefits under the DVA. The couple must hold themselves out to society as spouses for a significant period of time, must be cohabiting, unmarried and fulfill other conditions set out for a valid marriage (2). This observation will restrict other women who may be in live-in relationship for a short time (time is undefined) or are separated after living together for short duration. However, such a condition is under the purview of intimate partner violence.
The conservative Indian society restricts reporting of cases of domestic violence. A woman considers being tolerant to such abuse until it goes out of proportion or beyond her control. A study by INCLEN showed that at least 40% women had experienced at least one form of physical violence in their married life (3). Daga et al has found that many victims of domestic violence has either refused to name the perpetrator of the assault or attributed physical injuries to other reasons (4). Such a situation warrants screening of intimate partner violence in the hospital and health care settings. A careful observation along with the use of standardized tools for screening would certainly help in identification of victims of IPV, which has been grossly missed by doctors or health care providers. The problem lies in finding a suitable place having confidentiality in public funded health care facilities, time availability for screening in the overloaded out patient departments, a dedicated team to assess the risks, counsel and do timely intervention or referral. A client friendly environment without hostility to the affected women, non-judgemental attitude and cordial staff is needed for providing appropriate services to victims of IPV. The staff need to be trained in handling cases of IPV. Under the National AIDS Control Programme, Indian public hospitals have an Integrated Counselling and Testing Centre (ICTC). These ICTCs can be roped in to provide screening and counseling to victims of IPV besides emergency, ante natal or gynecology or surgical clinics.
References
1.The Protection of women from domestic violence Act, 2005. http://wcd.nic.in/wdvact.pdf (accessed on 19.5.2014).
2. Singh G. Court sets live-in relationship rules.http://wonderwoman.intoday.in/story/court-sets-livein-relationship-rules... (accessed on 20.5.2014).
3. International Clinical Epidemiologists Network (INCLEN). Domestic Violence in India 3: A Summary Report of a Multi-Site Household Survey. Washington, DC: International Centre for Development and Population Activities,2000.
4. Daga AS, Jejeebhoy S , Rajgopal S. Domestic Violence against Women: An Investigation of Hospital Causality Records, Mumbai’. Journal of Family Welfare,1999; 45 (1): 1-11.
Mongjam Meghachandra Singh
Professor, Department of Community Medicine,
Maulana Azad Medical College, New Delhi-110002.
Reeta Devi
Assistant Professor,
School of Health Sciences
Indira Gandhi National Open University
Maidan Garhi, New Delhi-110068.
Niharika Yedla
Former student, Sikkim Manipal Institute of Medical Sciences
Gangtok, India.
Vibhor Wadhwa
Former student,
Maulana Azad Medical College, New Delhi.
Competing interests: No competing interests
IPV Services Development: Sri Lankan Experience
This plenary presents an overview of Gender Based Violence (GBV) prevention services operated by the National Institute of Mental Health (NIMH), Angoda, (Sri Lanka).
GBV has major effects on both mental and physical health of affected women, men and their families. This can range from fatal outcomes like homicide, suicide, depression, physical injuries, chronic pain syndromes, somatisation and pregnancy related complications. GBV results in higher health costs, poor productivity, lower rates of human and social capital development and significant economic costs.
The primary emphasis is to curb the violence among the survivors and perpetrators who have mental illness, through evidence based pharmacological, social and psychotherapeutic interventions. However, the service has volunteered its services to civil sectors, where referrals can flow as self-referrals following media awareness, schools, universities, public sector offices, NGOs, private hospitals and legal mediation institutions. It also strives to prevent work place based sexual harassment.
I highlight the trajectory of service development by GBVPU, NIMH Angoda. At the onset, the unit conducted a series of training workshops aimed at increasing awareness of both primary care staff and mental health staff through MOH offices. Main aims were to empower the affected and build community based support groups. These were done with the help of Talangama, kaduwela, Hanwella MOH offices. A series of parallel educational events was incorporated into the curriculum of occupational therapist training, nurse training and sister training programs delivered through NIMH. Also, awareness programs were done for Samurdhi development officers. Medical input to the unit was provided through a lead consultant, respective senior registrars, dedicated medical officers who had special interest in the subject and specialist knowledge of major mental illness and its treatment. GBVPU, Angoda was involved in translating and validating the HITS (Hurts Insults threats and scream), IPV screening tool and incorporating it into initial assessments of most clients attending NIMH. A cross sectional survey was done of all attendees to GBVPU since 2011- 2016 to elaborate the frequency of major mental illness among the attendees. Further cross sectional study was done to capture the GBV spectrum and associated psychological distress in migrant labour workers of SLBFE (Sri Lanka Bureau of Foreign employment). Some of this work was presented at Ryerson university, SLMA conjoint conference held at BMICH in 2016. GBVPU delivered eclectic modalities of therapies based on behavioural, couple therapy, CBT, dynamic therapy, mindfulness and interpersonal therapy principals by a consultant psychiatrist or trained senior registrars.
This plenary offers conclusions and recommendations for future work of GBV prevention. It is essential to focus on the intensive medical treatment and case management of major mental illness of perpetrators, victims and the survivors. Prevention can be achieved by, increasing awareness of gender disparities, cultural beliefs, norms, and negative reinforcement of attitudes which foster violence. Interventions should best be multi-sectorial, finely collaborated, faceted, personally empowered, in liaison with already existing services, and supported well by existing laws and policies. Future planned activities include making a clear protocol for screening and management of GBV, formulating clear referral pathways, regular liaison with already existing services of ministry of health and other NGOs and to incorporate drama-therapy principals in relationships and family therapy work.
Competing interests: No competing interests