Background
Intimate partner violence (IPV) against women is a human rights violation and a global public health concern, as demonstrated by research over the past decade [
1‐
3]. Globally, the WHO multi-country study on women’s health and domestic violence found that the lifetime prevalence of physical or sexual partner violence, or both, varied between 15% and 71% in 10 countries [
4].
A major concern often argued in the provision of services for violence against women is to ensure that women are not re-victimised by the health sector, but are treated sensitively [
5]. Many studies have discussed health providers’ views and beliefs on IPV and their impact on the quality of services [
6‐
13]. Others have shown that their judgmental and directive attitudes and their lack of knowledge represent a major obstacle for abused women, often resulting in low disclosure [
14‐
18]. Misconceptions and stereotypes around IPV are present among many clinicians, who may feel that violence is normal, who may hold negative views about providing services for IPV, or think that women are to blame for their husband’s aggression, [
2,
19‐
25], or who seem to be more focused on physical illness [
7,
26]. Health care providers’ clinical responses are shaped by own personal experiences and socio-cultural beliefs [
27]. Providers often share the same cultural norms and practices of their patients, and similar gender values on IPV of the community – often experiencing violence themselves, as demonstrated by research from South Africa and the UK [
7,
22].
Moreover, the lack of training and knowledge about IPV combined with new tasks associated with IPV services have resulted in some health providers feeling overwhelmed and poorly equipped to intervene with abused women, and uncomfortable approaching IPV issues [
9,
23], especially when time is limited to deal with its social aspects [
6,
28‐
30].
Responses to IPV in Malaysia
Health provider responses to IPV and their effect on service provision are context and situation specific. This article focuses on a Malaysian model of health response to violence against women called One-Stop Crisis Centre (OSCC).
The OSCC model has been implemented in emergency departments of regional, specialized and district public hospitals (with various degrees of differences) by the Ministry of Health to offer medical and health services to domestic and sexual violence. At the OSCCs, women who experienced domestic violence receive on-site medical, psychological, and social support [
31]. The first OSCC was established in 1994 at the General Hospital, Kuala Lumpur, in collaboration with women's non-governmental organizations (NGOs), and was located within the Accident and Emergency (A&E) Department. Soon after, the Malaysian OSCC became a unique integrated model of care to women experiencing abuse, being implemented nationally through public hospitals across the entire country [
32]. Subsequently, other countries in the South East Asian region also replicated this model [
33,
34].
Only a few studies have been published in Malaysia about providers’ views and attitudes towards violence against women in general, mostly at primary health care levels [
35‐
38]. For instance, a study to assess the knowledge, attitudes and practices of primary health care providers regarding the identification and management of domestic violence in a hospital setting in Malaysia found that 28% of the clinicians and 51.1% of the nursing staff had inappropriate personal values regarding domestic violence and blamed the women for having done something to trigger their partner’s reaction [
37]. Moreover, the same study shows an underlying belief that domestic abuse is a rare and 'private matter'. More than half of the clinicians and a third of the nursing staff reported a fear of offending patients in asking about abuse. Over sixty percent of health care providers believed that the prevalence of domestic violence among their patients to be low [
37].
However, these studies do not fully reflect the range of attitudinal and systems challenges health workers are facing when trying to integrate a new package of services for women experiencing abuse. This article aims to fill this gap by exploring the views and attitudes of health providers towards IPV and abused women, and to investigate their impact on the provision and the quality of OSCC integrated services in Malaysia.
Methods
We employed a case study approach in this qualitative descriptive study allowing in-depth analysis of seven hospitals in 2 states in Malaysia. The aim was to analyse barriers and opportunities to implement and integrate effective health service responses to IPV at different levels of the health system in two Northern States in Malaysia. In particular, the overall study sought to: 1) explore and understand providers’ attitudes towards violence, 2) assess the training and organisational support they might receive to implement the policy around IPV, and 3) the challenges they faced when offering IPV services. The findings on policy developments and health systems issues have been published elsewhere [
39,
40]; this article presents the results from the health staff interviews on their views and opinions towards abuse and abused women (definition, acceptability, and their role as service providers) and how these can affect service provision.
In-depth interviews were selected as they can provide reliable and comparable data [
41], and allow for control over the questions and the topics to be covered in the discussion while leaving the interviewee the opportunity to tell his/her own account of issues related to the selected topics [
3]. Between January to April 2007, a total of 54 in-depth interviews were conducted with selected health providers (including nurses, medical officers, gynaecologists, medical social workers and hospital managers) who were responsible for providing services to abused women at different levels of hospital care: tertiary specialised facilities (Regional specialised hospitals), secondary ones (semi-specialised hospitals) and basic district settings (basic facilities with no specialists on site). Table
1 provides a summary of the type of providers interviewed.
Table 1
Numbers of interviews per type of providers
Counsellors
| 1 | 1 | 2 |
Medical assistants
| 0 | 2 | 2 |
Medical officers
| 14 | 8 | 22 |
Medical Social Workers
| 3 | 2 | 5 |
Obstetrics and Gynaecologists (OBGYN)
| 3 | 2 | 5 |
Psychiatrists
| 2 | 2 | 4 |
Staff Nurse/Nurse
| 8 | 6 | 14 |
Total
|
31
|
23
|
54
|
Staff were interviewed at a total of seven hospitals selected in two Northern States. In each State, a tertiary specialised hospital was selected, together with a secondary and a district setting (to get a sample of different levels of service with an OSCC). Snowball sampling was used to identify health providers, with the assistance of the local partners from the Universiti Sains Malaysia and the Head of A&E Departments. Respondents were selected according to their profession and their experience with violence issues and their connection with OSCCs.
Semi-structured interview guides were developed – and subsequently field- tested - to offer core questions around providers’ views about violence and their challenges when providing services to abused women. Key topics contained in the interview guides were:
-
Perceptions and views around domestic violence, abused women and their role as providers of IPV care: to understand whether providers’ attitudes impact on the services provided.
-
Clinical management: to help map the process of OSCC care and the daily practices around clinical management of abuse cases.
-
Guidelines and protocols: to get a sense of providers’ awareness and knowledge of hospital’s protocols and procedures around violence.
-
Training: to get a sense of knowledge of IPV that providers may have.
-
Collaboration with other agencies: to understand whether processes of collaboration among various sectors exist and how it works, and also providers views about it.
-
Perceptions of challenges faced when providing IPV services: to understand personal opinion about perceived barriers/challenges when dealing with abused women.
Written informed consent was obtained from each respondent. The majority of interviews were conducted in English by the principal investigator. Twelve interviews (primarily with nurses) were conducted in Bahasa Malaysia by two local research assistants, who had been previously trained on conducting qualitative interviews and on the content of the interviews-topic guides. The average length of each interview was around 45 minutes.
Digitally recorded interviews were saved onto a computer and subsequently transcribed. The twelve Malay interviews were subsequently translated verbatim into English. A local person and the field supervisor in Kelantan checked their fidelity towards the Malay version. A framework analysis method was then employed to analyse the emerging themes [
3,
42]. It consists of a content analysis method allowing for a systematic classification and organisation of data by major themes, categories and concepts within a thematic framework [
3]. This approach encourages the preservation and integrity of the voices and accounts of the interviewees, keeping the researcher grounded in the data, as the information is summarised and classified within a thematic matrix all along the analysis [
3].
The transcripts of in-depth interviews were read repeatedly to become familiar with the text, to have a full picture of the data collected, and to begin to identify some main themes throughout such initial reading. Once the cross-cutting thematic code framework was finalised, interviews were coded and managed by using NVIVO (N7), a qualitative software package.
Throughout the analysis, the code framework was further revised where new sub-codes and themes were identified and as linked themes were grouped together, reducing the number of broad overarching issues.
Ethical approval was granted by the Ethics Committees of the LSHTM and the World Health Organisation. Ethical permission for the study was also granted by the Economic Planning Unit of the Prime Minister’s Office and the Ministry of Health national ethical review committee in Malaysia.
Discussion
Most health care providers interviewed defined IPV as physical and emotional abuse only, and included acts such as scolding, hitting, beating, threats, emotional stress and deprivation. Only a few providers mentioned sexual abuse among the types of acts that may characterise IPV. There seemed to be some hesitation in defining IPV, as if the providers never thought of it before. This could reflect the lack of any reflective training when the OSCC services were integrated.
Our study also shows that there is a predominant perception of IPV as a family or marital issue, and therefore IPV is not seen as a public health matter, despite the fact that some acknowledged the physical and emotional consequences resulting from it. In general, IPV is not perceived as a priority health issue, probably, as some doctors said, because it is not “life threatening”. Although many disagree with violence as a means to solve marital conflict and label it unfair, being part of a culture that closes its eyes to violence against women seems to impact on the views of some health care professionals, and therefore may fall down the list of priorities in a busy A&E context, where most of the abuse cases may be found.
The findings presented in this article support the view that providers’ attitudes to IPV and their perception of their role could affect the quality of the services they offer. Our interviews showed that there seemed to be a link between providers’ view of IPV and of their perceived role and how they therefore responded to survivors of IPV. Providers who demonstrated less understanding of the socio-cultural determinants of abuse were also the ones who were more likely to focus on the injuries. For those who were more focused on the physical consequences of IPV, the emotional part of the care was frequently disregarded or not seen as part of their role. Thus if providers thought that their role was just within the medical domain, they might fail to recognise the complex interaction between medical and psycho-social aspects of IPV care, and were less likely to refer women for any additional services they may need. This reflects the findings of another study which shows that the psycho-social aspects of medical care are often undervalued, where the emotional aspect of IPV care goes often ignored and its ‘
social emergency’ is unrecognised [
43]. This lack of awareness of the psycho-social dimensions of IPV risks perpetuating the view that IPV is purely about a couple quarrelling which in turn can lead to inappropriate responses that could jeopardise women’s safety and impact on women’s views of the services as they can lose trust in the provider.
The study findings show that many providers could not empathise with women’s decisions of going back to their husbands, and women’s evasiveness and underreporting were often causes of frustration for them. Their sense of medical responsibility towards abused women and the perception of their role as “solver of patients’ problems” might have limited their empathy towards women – especially the ones who chose to remain in abusive relationships and do not accept their advice. In fact, despite their willingness to help, some still lacked respect for women’s choices. This may arise more from lack of understanding about how difficult it is for women to disclose or to leave an abusive relationship, especially without specialist support (emotional, practical, legal etc.), and also derives from low understanding about IPV being characterised by power and control issues. For example the existing literature [
9,
23] found that health professionals often do not comprehend that some women do not really have any alternatives, and often feel incapable of trying to influence patients to report, seek additional care and in referring them appropriately.
Our data show that some doctors see women as an obstacle in their perceived self-efficacy in the management of IPV, and do not understand the barriers women may face such as their financial and legal dependency on their husband, or the blame of the community, and the shame of a divorce. Not all respondents really recognised the courage required from women when seeking help. Such an attitude could be linked to the way some providers tend to focus on “fixing” the medical aspect of abuse and would tell a woman to leave the husband, rather than thinking about what the woman may really want. This may reflect the medical culture, which is primarily curative and thus sees the provider as the main decision-maker [
44]. This behaviour may also be related to a social class divide between doctors, who often belong to a higher socio-economic class than women who experienced abused. Moreover, this feeling of frustration, especially with “uncooperative women”, could be linked to the fact that providers think that it is difficult to offer an effective solution to women, especially when “successful” means convincing them to leave their husband. This issue is also raised in other settings [
7]. Providers may lack understanding of women’s disempowerment – and the social context of abuse and the gender inequalities leading to IPV - due to their social distance from the community, and thus their lack of understanding of the problem. Moreover, there was no understanding that their role may be feeding in a longer term process of change among abused women. Even if a woman does not feel able to leave a violent relationship, she would like recognition and support from her health provider, without being pressured to any action. This issue has been explored in other industrialised countries [
16]. Some women may not be ready to leave their husband and if health providers do not understand it, they may place women at more risk. More patient-centred and “stage-matched” interventions could be elaborated according to the various stages of change with regard to abuse [
17]. Health professionals should at least support women’s decisions, and, in the long run, contribute to the women’s ability in making a change to their situation [
45]. Referral to community support groups or NGOs, where they exist, can also be done and has been quite successful for example in Uganda (Michau and Nakar 2003).
There is the ongoing question about health care workers’ roles and in what ways they should be expected to help women. The contentious issue is whether their role should be purely medical or go beyond treatment [
27,
46]. The holistic management of IPV is not universally accepted as part of health personnel’s medical routine [
7,
47]. Our study shows that when providers follow the traditional role of treating and solving IPV as a “medical problem”, they tend to focus on the physical aspect of the injury and minimise the underlying cause of the problem. This does ensure that they at least treat the physical injuries of the patients, but it risks detaching providers from women’s personal experiences of IPV. Many practitioners seemed to feel helpless or inadequate when offering care to abused women. This was particularly true among staff at lower levels of hospital care, particularly where they had scarce resources, lack of local support services and limited access to training on IPV. Studies from other fields of health care also reported how some providers find offering emotional care to patients more difficult than any other aspects of clinical care [
26,
48]. The medicalised approach focuses mainly on the physical aspects of abuse and cannot help resolve women’s problem in the long term.
The feelings of inability or lack of self efficacy form an important part of the whole debate about what are realistic expectations for medical staff in terms of what they can do when addressing violence issues. In our study, providers’ sense of lack of self-efficacy is strongly bound up in the expectations of their professional role and what the meaning of successful patients’ outcome is. It seems that for many health providers the inability to resolve an abuse case – with a woman either reporting or leaving the husband – led to a feeling of inadequacy in their job.
On the other hand, our findings show that some doctors and nurses who would go beyond the limited medical role and argue they could provide more comprehensive care to women, taking a more proactive “advocate” role, offering advice and options of referrals and help channel women to additional care. This is an image that seems to be perceived primarily at tertiary care level, where they feel their role is to help women solve their problem not only by reassuring and calming them, but also by offering advice on support services. At district level, providers seemed to see their role as primarily being medical. Sometimes, this was due to unavailability of services on-site and locally, rather than unwillingness to help women. In general though, there seems to be a widespread uncertainty among providers about what their role should include. More sensitisation can help health care workers feel less inadequate.
The systematic and documented data collection and analysis employed in the study helped ensure that the process is auditable and replicable. Respondent validation was also used, which involved feeding back the research evidence to the research participants to confirm the findings. However, the study has several limitations. Firstly, it is based on a relatively small sample of practitioners and like all qualitative work is context-specific. However, it still sheds light on the dilemmas and frustrations that many health providers may face when responding to IPV, which could be addressed in training programmes and medical curricula to improve health responses to IPV. Secondly, it does not bring the perspective of the female clients directly, as they could not be interviewed because of ethical issues. However, the extensive literature research done to conceptualise this study does focus on women’s issues in order to voice their needs when implementing an integrated response.
Conclusion
Although many providers disagree with violence as a means to solve marital conflict and label it unfair, being part of a culture that ignores violence against women seems to affect the views of some health care professionals, and therefore it falls down the list of priorities in a busy A&E context.
Recognizing the impacts that providers views and attitudes on IPV and on their professional role can have on the quality of IPV services not only helps us comprehend why they operate in certain ways, but also make us realize the constraints that exist in promoting empathetic health care provision and which need to be addressed. More awareness training and sensitisation can help them feel less inadequate, especially if courses focus on women’s needs and strengths, how health providers can validate these and contribute to a longer term process of change for survivors of violence. A supportive, well resourced environment in terms of legal, counselling and police support services undoubtedly influences a health worker’s perceived ability to respond to violence. Clear guidance on how to record history of abuse, ask questions sensitively and validate experiences is also important together with training on good communication skills such as listening and being empathetic.
Competing interests
The authors declared that they have no competing interests.
Authors’ contributions
MC conceived the project, coordinated and conducted the study, analysed the data, and drafted the manuscript. SM helped in the conception of the study, contributed to data analysis and drafting of the manuscript. SHA participated in data analysis and help draft the manuscript. RS helped in the supervision of data collection, and contributed to data analysis. CW helped in the conceptualized the idea for the manuscript and the draft of the manuscript. All authors read and approved the final manuscript.