Not so long ago – 2001, to be precise – the health department issued The Primary Health Care Package for South Africa: A Set of Norms and Standards, which set out the main services patients could expect from primary healthcare facilities.
Deep within its pages was an idea ahead of its time: a health system response to domestic violence — one that required nurses to ask women with histories of depression, headaches, stomach pains or a partner known to be abusive about violence in their lives. Diplomatic inquiry into home life was also recommended when children failed to thrive, showed signs of recurrent episodes of trauma or behavioural problems.
Nurses were to be trained on how to ask such questions and were also to be given information sheets on domestic violence that they could share with patients, along with referral lists to shelters and other services.
But none of these plans came to be and the idea died on the pages of the government printer.
Now, in 2022, we have another chance to make good on this earlier vision. Section 18B(1) of the Domestic Violence Amendment Act says the health department must develop guidelines for the kinds of services that should be offered to patients who may be experiencing domestic violence. The provision is an opportunity to describe how such cases should be dealt with and ensure that this standard of care is routinely made available at clinics and hospitals.
Hospitals’ casualty sections and state mortuaries offer graphic examples of how domestic violence affects women’s health. Less visible, but perhaps more pernicious, is how domestic violence raises women’s risk of getting infected with HIV and other sexually transmitted infections and also contributes to obstetric complications such as pre-term delivery, stillbirths and induced abortions. Newborns are no less vulnerable, being underweight, unwell and undernourished at birth. Domestic violence also often has devastating effects on women’s mental health and emotional wellbeing.
By asking women about their relationships in a sensitive way, health workers can uncover whether their symptoms are linked to domestic violence. Termed “screening”, these carefully chosen questions tell the woman she can speak out about violence safely and in confidence, and that it’s not something that has to be passed over in silence. It also helps to offer a more holistic medical response, including referring women to further services and legal protection. This makes them less likely to be exposed to more violence and helps health workers to understand the reasons for a patient’s ill health, which means they can treat their symptoms better.
Yet there’s been almost no public pressure to demand a clear plan from the health sector to address domestic violence. And the services that are available at hospitals, through the Thuthuzela Care Centres, are geared towards complainants of sexual offences. This means women experiencing domestic violence will probably only receive trauma-informed health care when they are raped by their intimate partners. The courts and the police, coupled with a smattering of state and nongovernmental social care services, are their main recourse when it comes to violence.
There are other reasons the health sector doesn’t respond to domestic violence in the same way as to rape. First, domestic violence is not routinely picked up when women arrive at a hospital or clinic — even when they arrive at the emergency department with visible injuries. Moreover, health workers rarely refer clients to shelters or other support services.
Studies also show that many nurses have themselves experienced domestic violence, which may deter them from talking to their patients about the issue. Nurses and doctors are rarely trained on how to identify and deal with domestic violence, struggle with high workloads and do not have access to good systems of referral.
The frustration of not being able to “fix” women’s circumstances, coupled with clients’ perceived unwillingness to act on medical advice, has also caused health workers’ interest in addressing domestic violence to dwindle. And some simply don’t know how to ask questions that seem personal or intrusive.
Yet domestic violence is seen frequently in clinics and many health workers are keen to develop skills that will help them deal with this issue in patients’ lives. Three projects in rural, peri-urban and urban clinics show what is possible.
Some years ago Stellenbosch University piloted a project run by nurses. The programme adapted a screening protocol for domestic violence developed by the Western Cape Consortium on Violence Against Women and tested it at two urban and three rural primary healthcare facilities in the province. When the answers alluded to abuse, women were referred to complementary services, ranging from psychological support to help with getting protection orders. More than half of the women followed up a month after the intervention said it made a difference to their lives.
Safe & Sound, a counselling programme, coupled with 30 minutes of safety planning with abused women, was tried out at four antenatal clinics in Johannesburg, with promising results. In clinics where a quarter of pregnant women experienced violence from their partners, the project helped to bring down the odds of ongoing violence by half. The strategy also showed that training and job aids can increase nurses’ confidence and skills to help abused women.
In 2015, the humanitarian aid organisation, Doctors without Borders, began working with the North West provincial health department to create Kgomotso Care Centres at primary healthcare clinics. These centres offered clinical forensic examinations, screening and counselling to adults and children experiencing some form of sexual or domestic abuse. In an extremely rare example of a health department taking on a domestic violence project, the four clinics were to be handed over to the department in 2020. Although the project was promising, it is not clear if it has survived in the form originally envisaged.
The protocols tested by these three projects are ready to be incorporated in policies. But more than that their training programmes are based on everyday practice. The outcomes, along with what they revealed about mentoring and supporting health workers in their jobs, show what the effect of a programme of selective screening can be.
An important feature of both the Safe & Sound and Stellenbosch University projects was their selectivity. This means they didn’t try to screen every woman who walked through the clinic’s doors, but focused on those likely to be at risk: pregnant women in the case of Safe & Sound and women with a profile of symptoms in the Stellenbosch University intervention.
Given South Africa’s overburdened public health system, being selective about screening is key. And if screening is to succeed at all, then it should probably be prioritised for antenatal care, family planning, sexually transmitted infections (including HIV) and mental health services.
Selective screening at clinics is one part of a health sector response; emergency frontline care by nurses is another — as is implied by the section of the Domestic Violence Act that says the police have to ensure that women have access to emergency medical treatment.
Paramedics employed by emergency medical services are often the first to arrive at a scene of violence. As front line workers, they’re in a good position to detect domestic violence and to medically treat and refer victims to further care. For this reason, the Cape Peninsula University of Technology has experimented with training approaches suited to paramedics.
Casualty doctors are just as important. At the very least, they should be recording who caused their patients’ injuries and referring them to the right services. The Health Professionals Council of South Africa’s guidelines for screening for domestic violence give advice on how to ask helpful questions. The University of Cape Town has also crafted guidance for healthcare professionals and incorporated this into its curriculum for medical students.
Psychosocial services must be integrated in the health sector response, so staff based at Thuthuzela Care Centres need to be trained to provide emotional support to victims of abuse and to refer them to services where they can get extra support. These systems need to work both ways, with clinics and hospitals also accepting referrals from shelters, especially for mental wellbeing.
Domestic violence also needs to be incorporated into medical and nursing students’ curricula while the materials for nurses could be adapted as part of in-service training for those who have already qualified.
The department of health did intend to address domestic violence at one point. Doing so now would be a genuinely novel addition to current interventions. With the ground having already been laid for a simple and helpful approach by the health sector, what will it take to nudge them onto this new terrain?