Improving the health sector response to gender-based violence has implications for many aspects of the way a clinic functions. For example, ensuring adequate care for women who experience violence may require private consultation spaces, written policies and protocols for handling cases of violence, client flow that facilitates meaningful care, access to emergency contraception, and a directory of referrals in the community. One way to assess what resources exist in a clinic is to have an independent observer visit the clinic and assess the situation through firsthand observation. Another way to do this is for a group of staff to complete a checklist or self-administered questionnaire that includes resources that are important for providing quality care to survivors of violence.
Some methods that can be used include:
- Clinic observations
- Confidential interviews with clinic staff are an excellent source of information about the infrastructure, protocols and capacity of the health care facility. However, they require time and confidentiality assurances, and staff may not want to get involved in critical evaluations of the facility that employs them.
- Questionnaires/ management checklists are an easy, resource friendly monitoring mechanism. A management checklist can be used for monitoring what measures an institution has taken to ensure an adequate response for women experiencing gender-based violence.
- Review of protocols and policies
Assessment and Monitoring Checklist of Minimum Key Elements of Quality Health Care for Women Victims/Survivors of Gender-Based Violence
All health organizations have an ethical obligation to assess the quality of care that they provide to all women, whether through full evaluations and/or ongoing, routine monitoring activities. An assessment could also look at the minimum elements required to protect women‘s safety and provide quality care in light of widespread gender-based violence, as listed below:
1. Institutional values and commitment: Has the institution made a commitment to addressing violence against women, incorporating a ―system‘s approach? Are senior managers aware of gender-based violence against women as a public health problem and a human rights violation, and have they voiced their support for efforts to improve the health service response to violence?
2. Alliances and referral networks: Has the institution developed a referral network of services in the community, including to women‘s groups and other supports? Is this information accessible to all health care providers?
3. Privacy and confidentiality: Does the institution have a separate, private, safe space for women to meet with health care providers? Are there protocols for safeguarding women‘s privacy, confidentiality and safety, including confidentiality of records? Do providers and all who come into contact with the women or have access to records understand the protocols?
4. Understanding of and compliance with local and national legislation: Are all providers familiar with local and national laws about gender-based violence, including what constitutes a crime, how to preserve forensic evidence, what rights women have with regard to bringing charges against a perpetrator and protecting themselves from future violence, and what steps women need to take in order to separate from a violent spouse? Do health care providers understand their obligations under the law, including legal reporting requirements (for example, in cases of sexual abuse) as well as regulations governing who has access to medical records (for example, whether parents have the right to access the medical records of adolescents)? Does the institution facilitate and support full compliance with obligations?
5. Ongoing provider sensitization and training: Does the institution provide or collaborate with organizations to provide ongoing training for staff around gender-based violence, harmful norms and practices, legal obligations and proper medical management of cases?
6. Protocols for caring for cases of gender-based violence: Does the institution have clear, readily available protocols for screening, care and referral of cases of gender-based violence? Were these protocols developed in a participatory manner, incorporating feedback from staff at all levels as well as clients? Are all staff aware of and able to implement the protocols?
7. Post-exposure prophylaxis, Emergency contraception and other supplies: Does the institution have supplies readily available, and are staff properly trained on their dissemination and use?
8. Informational and educational materials: Is information about violence against women visible and available, including on women‘s rights and local services women can turn to for help?
9. Medical records and information systems: Are systems in place for documenting information about violence against women as well as collating standardized data and service statistics on the number of victims of violence? Are records kept in a safe, secure manner?
10. Monitoring and evaluation: Does the institution integrate mechanisms for ongoing monitoring and evaluation of their work, including receiving feedback from all staff as well as from women seeking services? Are there regular opportunities for providers and managers to exchange feedback? Is there a mechanism for clients to provide feedback regarding care?
Source: Adapted from Bott, S., Guedes, A., Guezmes, A. and Claramunt, C., 2004. Improving the Health Sector Response to Gender-Based Violence: A Resource Manual for Health Care Professionals. NY, NY: International Planned Parenthood Federation: Western Hemisphere Region. Available in English and Spanish.
Case Study: Agency for Healthcare Research and Quality (AHRQ, USA)
The Agency for Healthcare Research and Quality has been supporting, through partnerships, rigorous research to improve the health care response to domestic violence in the United States. They have contributed to:
- Identifying gaps in research and pointing to the need for a stronger evidence base in the areas of screening, detecting and providing services to survivors.
- Helping health care workers screen for and identify women who have experienced domestic abuse.
- Creating tools that help health care workers counsel and provide services to survivors.
- Developing tools for assessment and evaluation of domestic violence programs.
The evaluation tools (DELPHI) were developed by AHRQ based on consensus and are for use in hospital-based settings. They include:
1. Hospital Policies and Procedures
2. Hospital Physical Environment
3. Hospital Cultural Environment
5. Screening and Safety Assessment
To learn more about the AHRQ, see the website.
How to Conduct a Situation Analysis of Health Services for Survivors of Sexual Assault (South African Gender-based Violence and Health Initiative and Medical Research Council of South Africa). This guide provides tools and outlines steps for conducting a situation analysis of the quality of health services for victims/survivors of sexual assault. It includes a facilities checklist for collecting information on the infrastructure of the facilities where survivors are managed and where medico-legal/forensic examinations take place, including medication, equipment and tests available at the facility. It also includes a standardized health care provider questionnaire designed to be used in face to face interviews with health care providers who manage the care of survivors. Note that, the tool does not address stigma and discrimination, the time a patient waits to be seen by a provider, or what happens after the provider has completed the examination. Available in English.
Clinic Interview and Observation Guide (International Planned Parenthood Federation/Western Hemisphere Region). This assessment tool gathers information on the human, physical, and written resources available in a clinic. The first half of the guide consists of an interview with a small group of staff members (for example, the clinic director, a doctor, and a counselor). This section includes mostly closed-ended questions about services, including: the clinic‘s human resources; written protocols related to gender-based violence screening, care, and referral systems; and other resources, such as whether or not the clinic offers emergency contraception. The second part of the guide involves an observation of the physical infrastructure and operations of the clinic, such as privacy in consultation areas, as well as the availability of informational materials on sexual violence. Available in English and Spanish.
STI/HIV Self-Assessment Module (International Planned Parenthood Federation/Western Hemisphere Region). This self-assessment module contains a questionnaire designed to assess whether an organization has the necessary capacity, including management systems, to ensure high quality sexual and reproductive health services. The questionnaire allows staff from different levels of an organization to assess the extent to which their organization has addressed a multitude of issues relevant to gender-based violence, including sexual violence. Available in English and Spanish.
Management of Rape Victims Questionnaire (Azikiwe, Wright, Cheng & D‘Angelo, USA). This self-administered questionnaire was designed for programme directors of pediatric and adult hospital emergency departments to report on their department‘s management of care for rape survivors. The 22 questions gather information concerning the department‘s volume of rape cases, screening for STDs, emergency contraception policies, medications offered or prescribed for emergency contraception, non-occupational HIV post-exposure prophylaxis policies, medications offered or prescribed for HIV post-exposure prophylaxis, and patient follow-up. Available for purchase in English from Elsevier.
Using Mystery Clients: A Guide to Using Mystery Clients for Evaluation Input (Pathfinder International, 2006). This guide provides background on the concept of mystery clients and details the process of conducting and reporting on mystery client interviews within health facilities. Available in English.
Standardized Interview Questionnaires and Facilities Checklist (Christofides, Jewkes, Webster, Penn-Kekana, Abrahams & Martin, South Africa). This face-to-face interview questionnaire was designed to gather information from health care providers who care for rape survivors. The questionnaire contains 5 sections that collect information on: the demographic characteristics of providers; the types of services available for rape survivors; whether care protocols for rape survivors are available at the facility; whether the practitioner had undergone training in how to care for rape survivors; and practitioner's attitudes towards rape and women who have been raped. Responses to particular items are used to develop a scale that measures the quality of clinical care. In addition, the assessment tool includes a checklist that the fieldworkers complete at each health care center noting the presence or absence of equipment and medicines and the structural quality of the facilities. The Interview Questionnaires and the Facilities Checklist are available in English.
Quality of Care Composite Score (Christofides, Jewkes, Webster, Penn-Kekana, Abrahams & Martin, South Africa). The Quality of Care Composite Score is a self-reported measure used at the individual practitioner level to assess the clinical care provided by doctors and nurses who care for rape victims in terms of indicators of preventive strategies for sexually transmitted infections and prevention of pregnancy, counseling, and the quality of forensic examinations. It consists of 11 items such as treatment of sexually transmitted infections and clothing or underpants ever sent for forensic testing. Available in English.
Ver y Atender! Guía Practica para Conocer cómo Funcionan los Servicios de Salud para Mujeres Victimas y Sobrevivientes de Violencia Sexual (Troncoso, E., D. Billings, O. Ortiz and C. Suarez/UNFPA and Ipas, 2006, Latin America). This guide includes a tool that can be used to conduct a facility based assessment of services or referrals that could/should be offered for survivors; protocols and processes; capacity for conservation and collection of data; and HIV diagnosis and Post-Exposure Prophylaxis for different age groups. Available in Spanish.
A Practical Approach to Gender-Based Violence: A Programme Guide for Health Care Providers and Managers (Billings/UNFPA, 2001). This Guide includes information on undertaking a situational analysis on p. 44. Available in English, French and Spanish.
Evaluating Domestic Violence Programs (United States Agency for Healthcare Research and Quality). This instrument facilitates a formal performance assessment of a hospital's domestic violence programme and was developed by a panel of experts focused on examining structure and process measurements. The evaluation tool measures nine categories which are explained through online instructions: hospital policies and procedures; hospital physical environment; hospital cultural environment; training of providers; screening and safety assessment; documentation; intervention services; evaluation activities; and collaboration with other service providers. The materials, including the facility assessment tool are available in English.
Twubakane Project Inventory to Assess Facility Readiness to Manage Gender-based Violence (IntraHealth, 2008). Available in English and French.