Latin American and Caribbean countries’ baseline clinical and policy guidelines for responding to intimate partner violence and sexual violence against women

The challenges we experienced in obtaining current national policies and clinical guidelines on IPV and SV in LAC are illustrative of some of the difficulties of conducting health and policy research in low- and middle-income countries. We acknowledge the limitation that one third of all countries approached did not respond. The low response rate limited researchers’ ability to carry out subregional comparisons. Nevertheless the information we obtained from the 66.7 % of countries we approached provides a useful baseline snap-shot of the strengths and gaps to inform the implementation of the July 2013 WHO Clinical and Policy Guidelines.

Policies:

National policies we obtained were fairly comprehensive in terms of covering physical, emotional, and sexual violence and some displayed good intersectoral collaboration by involving a number of government and civil sectors, which are vital for a strong government and community response to IPV/SV. The policies were commendably strong in addressing violence prevention and how to respond to IPV/SV in women and children in a supportive manner. The greatest gap was in the training of health-care providers in virtually all aspects of care for IPV/SV survivors essential for an adequate response.

Clinical Guidelines:

Women-centered care for IPV/SV survivors was especially strong in the important areas of privacy, confidentiality, danger assessment, safety planning, and supportive reactions to disclosure. Strength was also evident in providing written information and referring to legal, housing and economic empowerment services by a referral pathway. Women with special needs related to mental disorders and/or physical disability and referrals and referral pathways for services were also fairly well addressed. Moderate gaps were evident in selective enquiry for IPV, SV, assessing mental health (suicide, self-harm, depression, anxiety), providing mental health services, psychological first aid, watchful waiting to see if early distress resolves, providing or mobilizing social support, and structured advocacy and empowerment programs. Moderate gaps were also seen in assessing and providing for children’s safety, providing psychotherapy for children exposed to IPV and meeting the special needs of pregnant women, all of which are essential issues. Documentation with a body diagram or photo of injuries if present which may be essential for legal proceedings was also a moderate gap. Large gaps were evident in advising on coping strategies for stress and assessing for substance abuse and posttraumatic stress disorder. Large gaps were also present on advising women on the potential risks of taking home written materials, directories of existing services, shelters and hotlines, all of which are critical aspects of a healthcare response to IPV/SV. Unfortunately, the WHO guidance does not address IPV/SV in same sex relationships and as our project was to examine baseline adherence to the WHO Clinical and Policy Guidelines, we did not include this important topic in our scoring matrix.

There were additional strengths in the care of SV survivors; most guidelines appropriately did not require STI testing before treatment or HIV testing before post-exposure prophylaxis (PEP), advising about recording the time and type of assault, the need for vaginal swabs, the risks of pregnancy, STI’s, Hepatitis B and HIV and emergency contraception within five days of SV. Moderate gaps for survivors of SV were seen in the availability of sexual assault services available 24/7 and the need to collect anal and oral swabs and hair and fibers to assist in legal proceedings. Specific advice about types of emergency contraception, referral for abortion where legal, specific treatment for various STI’s, and offering hepatitis B vaccine were moderate gaps. HIV testing and counselling at first consultation, HIV-PEP appropriateness counselling, shared decision making, starting HIV PEP within 72 h, 2 or 3 drugs for HIV PEP, regular follow-ups, offering adherence counselling, and using drugs that followed national guidelines were also moderate gaps. Large gaps for SV survivors included prioritizing drugs with fewer side effects, although this decision may have been pre-empted by national drug guidelines.

The largest gaps noted were in the area of providing training to healthcare professionals who are often the most trusted and consulted by victims of violence. We asked about content, frequency and timing (in-service/prequalification) training, but assessing quality was outside the scope of this effort. Evidence suggests that “one-shot training” is not sufficient and trainings should be repeated/ongoing but this is not what occurs in low- and middle-income countries. The WHO Guidelines state “training should be intensive and content-appropriate to the context and setting. Intensive multidisciplinary training…should be offered to health care professionals where referrals to specialist domestic violence services are possible” (11: pp 35–36). Only half of the guidelines advised in-service training for frontline healthcare providers and provided information to them about IPV/SV and the best ways to respond to disclosure. Large gaps were reported on nearly all training items in the WHO Clinical Guidelines. None of the guidelines included training of prequalification healthcare workers or how direct healthcare providers should collect forensic evidence, so necessary for legal prosecution of perpetrators. Only one guideline suggested the length and frequency of training and there was poor psychological support for vicarious trauma among healthcare providers caring for IPV/SV patients. Clearly training is a crucial step in implementing the WHO Clinical and Policy Guidelines [11].

However, development of policies and guidelines is only the first step; monitoring and evaluating services for IPV/SV survivors are essential for implementation. Large gaps were reported in promotion of mechanisms and meetings for intersectoral collaboration and evaluation of services. To the best of our knowledge, there are no regional efforts to assess the implementation of health sector policies/protocols, though there may be some ongoing country-specific initiatives. The gap between policy, funding and implementation is key. PAHO is currently preparing a Regional Strategy and Plan of Action on strengthening health systems to address VAW to be reviewed and (hopefully) approved by Ministers of Health from 35 countries in the Americas. This document highlights the gap between policy and implementation and tries to push for advancements in terms of the creation of dedicated budget lines for VAW work within health budgets, for instance. Optimal evaluation should include intersectoral collaboration as well as input from women survivors of IPV/SV. Intersectoral collaboration is essential to improve policies and services, but also to change the public perception against IPV/SV especially in patriarchal societies where VAW may be tolerated or ignored.