State plans to improve its health systems' response to domestic violence have largely failed to take off, but now there is a fresh opportunity for healthcare workers to play a key role in helping victims of abuse.
In 2001, the Health Department issued The Primary Health Care Package for South Africa: A Set of Norms and Standards, listing the main services patients could expect from primary healthcare facilities.
It contained a health system response to domestic violence – requiring 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 and showed recurrent signs of trauma or behavioural problems.
Nurses would be trained on asking such questions and would get information sheets on domestic violence that they could share with patients, with referral lists to shelters and other services.
But none of these plans happened, and the idea died.
Now, in 2022, we have another chance to make good on this earlier vision, writes the Bhekisisa Centre for Health Journalism in the Mail & Guardian.
Section 18B(1) of the Domestic Violence Amendment Act says the health department must develop guidelines for services to be offered to patients experiencing domestic violence. This is an opportunity to describe how such cases should be dealt with and ensure this standard of care is available at clinics and hospitals.
Hospitals’ casualty sections and state mortuaries offer graphic examples of how domestic violence affects women’s health. Less visible is how it raises women’s risk of HIV and other sexually transmitted infections, and contributes to obstetric complications like pre-term delivery, stillbirths and induced abortions.
By asking women about their relationships in a sensitive way, health workers can uncover whether their symptoms are linked to domestic violence. These questions tell the woman she can speak out safely and confidentially. They can also refer women to further services and legal protection
Yet there’s been almost no public pressure to demand a clear plan from the health sector to tackle domestic violence. And the services 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 their partners rape them.
The courts and the police, and a smattering of state and non-governmental 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 hospitals or clinics.
Nurses and doctors are rarely trained on how to identify and deal with domestic violence, and do not have access to good systems of referral.
Yet domestic violence is seen frequently in clinics and many health workers are keen to develop skills to help them deal with this issue.
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. When the answers alluded to abuse, women were referred to complementary services, from psychological support to help with getting protection orders. More than half of the women followed up a month later 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, and in clinics where a quarter of pregnant women experienced violence from their partners, the project halved the odds of ongoing violence.
In 2015, Doctors without Borders began working with the North West Health Department to create Kgomotso Care Centres at clinics. They offered clinical forensic examinations, screening and counselling to adults and children experiencing sexual or domestic abuse.
In a 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. It is not clear if it has survived in the form originally envisaged.
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 police must ensure women have access to emergency medical treatment.
Paramedics employed by emergency medical services are often first to arrive at a scene of violence. 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 equally important and 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 at Thuthuzela Care Centres must be trained to provide emotional support to abuse victims and refer them to services for extra support.
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 already qualified.
See more from MedicalBrief archives:
Gauteng improves capacity to cope with gender-based violence
Violence during pregnancy a way of life for many SA women
SASOG introduces guidelines for routine screening for GBV
Most Limpopo burn patients are male victims of intimate partner violence
16 Days of Activism: SASOG calls health care professionals to action