Making Rural Healthcare System Responsive to Domestic Violence: Notes from Patan in Gujarat

Domestic violence encompasses any form of violence perpetrated against a person by their biological relatives, but predominantly, it is the violence against a woman by male members of her family and/or relatives (Elsberg et al 2008; Martin et al 1999). The global estimates suggest that more than one in three (35%) women worldwide have faced physical or sexual violence in their lifetime. Violence by an intimate partner is the most common form of domestic violence, and almost one-third (30%) women who have been in a relationship report that they have experienced some form of physical and/or sexual violence from their partner in their lifetime (WHO 2017). 

The data on domestic violence in India is equally depressing, matching with the global scenario. According to the National Family and Health Survey (NFHS) conducted in 2015–16, the total lifetime prevalence of domestic and sexual violence against women in the age group of 15–49 years have been 33.5% and 8.5% respectively. In the 12 months preceding the above survey, 26% women had either experienced domestic or sexual violence (IIPS 2017). 

Domestic violence negatively affects women’s physical, mental, sexual, and reproductive health, and is associated with considerable morbidity and mortality (WHO 2017; WHO 2013; Ambuel et al 2009). Among married women in India who have experienced spousal physical or sexual violence, one-fourth have been observed to have sustained some kind of injury (IIPS 2013). 

Globally, it has been observed that women who are adversely affected in terms of physical, mental, sexual, and reproductive health due to domestic violence have been making extensive use of healthcare resources (Campbell 2002; Koss et al 1991). So, it is important to note that domestic violence is a public health issue.^[1]  The public health system has emerged as one of the critical sites across the world for addressing domestic violence and the resulting consequences. The past decade has seen several initiatives on this front, largely in urban civil hospitals to respond to a wide range of violence-related complaints, including rape, sexual assault, and other forms of physical abuse.  

Given that 68% of the Indian population lives in rural areas, there is a greater need to engage with domestic violence in villages. Women in rural areas (36%) are more likely than those in urban areas (28%) to experience one or more forms of spousal violence (IIPS 2017: 569). 

While evidence indicates that public hospitals and associated healthcare professionals in urban areas are uniquely placed to intervene and prevent violence against women, there is a pressing need for a similar mechanism in rural areas to combat gender violence (Utsa et al 2012; Kathuria et al 2018). In devising such solutions for rural areas, one has to bear in mind certain specific issues in villages, both in terms of the nature of violence and the consequences emerging out of such violence. The redressal system in rural areas needs to factor in these qualitative differences, compared to the situation in the urban areas. Such a structural response is called for as rural women survivors of domestic violence suffer from aggravated “isolation” as they lack social/familial support, experience limited mobility, have little access to information, and are dictated by cultural norms that emphasise their location as one of the most suppressed members within the marital household, with limited to no decision-making agency. 

Peek-Asa et al (2011) investigation has found that violence against women by their intimate partners is more frequent and common in villages compared to urban areas. Accordingly, among women screened for intimate partner violence between November 2006 and July 2008, 61.5% of isolated (lacking any social support) rural women reported four or more instances of physical violence compared to 39.3% of urban women. More than 30% of the isolated rural women reported severe to very severe physical violence compared to 10% of urban women (Peek-Asa et al 2011: 1,745).

This article presents a unique model developed by the Society for Women’s Action and Training Initiatives (SWATI) in the villages of Patan district in Gujarat to tackle domestic violence. The novel initiative, which began in 2012 in Radhanpur, has been setting up violence prevention and support centres in hospitals to extend support to the victims of domestic violence. The idea behind such centres has been to do with the fact that despite women have limited mobility in villages, owing to regressive structures, they are allowed to access healthcare services for themselves and for their children. While setting up such centres within villages could have invited trouble from the families of victims and/or local communities, SWATI’s initiative has demonstrated that several women have been able to come forward to seek redressal to their plight, and also to escape further violence.    

Roadmap for a Model 

For over the past two decades, SWATI has been systematically engaged in preventing violence against women by empowering them to combat violence, challenge community mindsets, and to work towards making criminal justice system, the police, and judiciary responsive to the cases of violence against women. Working on the ground in coordination with various communities, SWATI has realised that gender violence is a complex social phenomenon, augmented by an intertwining matrix of caste, class, access to education and healthcare, mindset of individuals and communities, among others.   

Consequently, the efforts to combat gender violence should not only factor in various angles behind violence but should also intervene at multiple levels in the community over a stretch of time. Since SWATI’s primary work concerns rural women, the organisation has been making efforts to strengthen available institutions in villages to detect and prevent violence against women.    

The focus on healthcare sector response to combat violence against women has been borne out of SWATI’s understanding of women’s poor health and the secondary social status accorded to them by the communities in which they live. The existing interaction between local healthcare sector and Mahila Nyaya Panchayats (MNPs)^[2]  has also come in handy in SWATI’s efforts to affirm the need for medical reports as an important piece of evidence before the courts to prove violence against women.  

Learning by Having an Ear to the Ground

In the past, MNP leaders found that the medical reports do not mention domestic violence and abuse against women, when they had tried to present the victim before the court to seek justice. Having realised this, MNP women accompanied every domestic violence victim to hospitals and ensured that the doctors mentioned violence and injuries in their reports. When women went to hospitals on their own, the doctors made light of the victim’s injuries and sufferings and undermined their confidence by pointing out the possible implications of filing a police complaint. Not only had this prevented women from taking further action, but it also amounted to the humiliation of victims by the system.^[3] SWATI has been able to overcome such obstacles by ensuring that an MNP representative accompanied victims of domestic violence to hospitals. From this, we have learnt that there is an urgent need to sensitise the staff working in the healthcare system to provide an empathetic response to gender violence victims.       

Formulation of a Model for Villages

As discussed above, the challenges in rural areas are markedly different from urban centres, and therefore, there is a need for a different approach. Accordingly, SWATI’s model to prevent gender violence in villages has been involving multilayered and differentially-located^[4] public health systems to ensure women’s access to violence prevention and support cells located in the hospitals. Barriers such as the lack of anonymity and social taboos that prevent rural women from seeking violence-prevention support from formal institutions have been negotiated through an upward referral chain in the healthcare system.  

Thus, healthcare providers at village- and district-level, such as Accredited Social Health Activist (ASHA) workers and others at sub-centres, primary health centres (PHCs), and community health centres (CHCs) have been made part of an upward referral system (bottom-up approach) to refer women to hospitals where violence prevention and support cells are located. 

ASHA workers have been a key element of this chain. ASHA workers are supported at the village-level by village health and sanitation committees, Anganwadi workers, auxiliary nurse midwives (ANMs), and medical officers. At the cluster level, ASHA workers are supported by their supervisors, and at the block- and district-level, respective community mobilisers extend support to ASHA workers. They also are in regular contact with the block-level CHCs/tertiary care hospitals, as they are involved in bringing women to CHCs for antenatal check-ups. The intervention by SWATI has been leveraging this support structure by training ASHA workers to detect domestic violence and to prevent it at the local level. Based on the need, they have been referring victims to an established domestic violence support cell, located at the block- or district-level.  

Recognising the need to ensure the safety of ASHA workers, all efforts have been made to not put them at risk due to their intervention in combating gender violence. The intervention design has several pathways of support or referral that an ASHA worker could follow, based on her informed assessment of what is required and what is feasible in a given situation. 

This model for rural areas thus has several components, some common to other models and some specifically to respond to the needs of rural areas. The commonalities include: a designated pathway of referral to a violence prevention cell/counsellor in a tertiary care hospital; orientation of medical staff and creation of an environment in the healthcare system to accept violence as its concern, and the establishment of a system for the recording-keeping of domestic violence victims, among others. Where the rural intervention differs is in the involvement of community healthcare providers, such as ANMs, local medical officials, community leaders, local panchayats, among others. As a part of this intervention, SWATI has initiated cells at the hospital level, has been working towards the creation of a referral chain, and employing sustained measures to raise awareness among communities in rural areas.

The Evolution of Support Cells 

The first violence prevention and support cell (Mahila Sahayta Kendra) was established in Radhanpur block of Patan district on 10 July 2012. The cell has been operational with the joint efforts of Referral Hospital and Community Health Centre, Radhanpur and SWATI staff. While the hospital has been providing space, SWATI offers training to hospital staff. The cell has been recognised as the first of its kind in Gujarat, and perhaps, in the country for a public health department and a non-governmental organisation (NGO) to come together to work on the domestic violence against women. 

The location of the cell at a CHC has played a crucial role in its success. The Radhanpur cell has been established at a CHC but not at a PHC, notwithstanding the fact that a CHC is at a farther distance compared to a PHC for the victims in the villages. This has been done to mitigate the effects of regressive social structures in rural areas that prevent women from villages to seek help against domestic violence, if such a facility is located at a PHC in the village. The presence of local staff at PHCs could result in the breach of confidentiality and put the woman at the risk of worsened violence, along with clinic staff, from the irate members of the survivor’s family and/or local community. 

Additionally, the brutality of violence and nature of injuries make it necessary for the victim to be examined by specialist doctors, and often involve in registering a medico-legal case (MLC), which is possible only at a referral hospital. In such health facilities, women also have higher chances to remain anonymous due to a large number of patients at the outpatient wards of these hospitals. While SWATI had taken three years to establish the Radhanpur cell, domestic violence prevention and support cells were established at General Hospital in Sidhpur and GMERS Medical College and Hospital in Dharpur in 2016 alone.  

The Establishment of Radhanpur Cell

To begin with, an orientation session was organised for the hospital staff to help them understand domestic violence, its health consequences, and the role of the Radhanpur cell. This was followed by an awareness campaign in the community to enable women to reach out in the event of domestic violence. A series of posters explaining what one could do in the event of domestic violence were prominently displayed in the hospital premises. A news ticker on a local cable channel, which reaches the population in three blocks, carried the information and contact details of the cell. Pamphlets providing brief information about the role of the cell and contact information were distributed to outpatients and their relatives in the hospital waiting area as well as to ASHA workers who accompanied women to the antenatal clinic (ANC). 

Analysing counselling case records showed us that healthcare providers themselves were among the first few cases. Female staff at the hospital and ASHA workers who accompanied women to ANC and for tubal ligation at the hospital approached the counsellor after reading about the cell.  

Three years after the cell was established, informal interactions between ASHA workers and counsellors turned into brief orientation sessions on domestic violence, its health impact, gender sensitisation, and the rights of women. This has motivated ASHA workers to refer women facing violence to seek redressal through the cell. In three years after the cell was established, SWATI had been able to train 281 ASHA workers from three blocks which fall under Radhanpur Hospital as regards the domestic violence cases. At this point, the role of ASHA workers had been to provide information to victims about the cell to inform the victim’s family (natal) of the violence, and to call 181 women’s helpline number, and, in a few cases, personally accompany women to the cell.

In the period January 2016–June 2018, the cell at Radhanpur hospital received 250 referrals. Referrals from hospital staff (doctors, nurses, attendants, and others) accounted for 19% (55/295), 9.6% (24/295) from ASHA workers, and satisfied clients, who benefitted from the cell, referred 22% (64/295) cases. Self-referrals by survivors, approaching the cell directly, stood at 15% (45/295) (SWATI 2018).  The cell also received referrals from community leaders, police personnel, staff from the local court, among others. 

Initial response at the Radhanpur cell had been effective and to the satisfaction of survivors in resolving cases. However, a hospital-based cell is limited in its scope to prevent or even detect cases of domestic violence in their early stages. For example, in a particular case, the cell was able to come to the rescue of a woman only after she had visited hospital multiple times with injuries resulting from brutal violence. At the time she was referred to the cell, she refused to file a police complaint against her assaulters. It was observed that the woman in question had a history of five MLCs in the span of 10 years. Finally, the cell was able to help her to escape violence after counselling (SWATI 2016).

Expansion of Support Cells

In order to intervene swiftly and to reach out to as many women as possible, SWATI has worked towards the development of an upward referral chain by expanding the initiative to other hospitals. With the expansion of the cell to two other hospitals at Sidhpur and Dharpur, SWATI has focused on the systematic development of an upward referral chain as one of the strategies for the early detection and referral of victims facing violence. Community-level screenings by ASHA workers, who act as front-line health workers, are central to this chain. 

The inclusion of domestic violence against women as one of the health issues in the guidelines and manuals of ASHA workers in 2015 has been providing legitimacy to the SWATI initiative. It has been found that there are several advantages in involving ASHA workers in the process of early detection and referring victims to the cells. The benefit of involving ASHA workers in the initiative stems from the fact that they are village residents and visit every household in their jurisdiction at least once a month. It is to be noted that most of the villages in India have ASHA workers, and one ASHA worker is assigned to a population of 1,000.  Additionally, the ability of ASHA workers to notice non-physical violence has been already demonstrated from the data gathered from Radhanpur cell.

The process of involving ASHA workers in detecting and referring victims of domestic violence to cells in Sidhpur and Dharpur hospitals began with training. The support received from the block health officials has facilitated the process. Till date, over 550 ASHA workers in five blocks in Patan have been trained in a three-phase training process. At the orientation level, a session was dedicated to eliciting and documenting social and clinical symptoms ASHA workers associated with domestic violence among women and noticed at the community level. Subsequently, a field study was carried out to document the efficacy of ASHA workers in identifying women facing violence and resulting morbidities during the course of their regular work. Besides, ASHA workers were asked to interview women under their jurisdiction whom they thought to be facing domestic violence.

The information on 1,181 women whom ASHA workers suspected of facing violence was gathered. It is worth noting that for 89% (1,056 of the 1,181) women ASHA workers’ assessment of whether or not a particular woman faced domestic violence matched with what women reported. None of the women whom ASHA workers believed to be experiencing severe domestic violence denied it (SWATI 2018). Another important finding of the study has been that 78% (813 of the 1,046) women approached ASHA workers for treatment. 

After concluding the training, counsellors from the cells have been following up with ASHA workers periodically to track referrals as well as to extend support. After the orientation, where needed, ASHA workers have been involved in community-level monitoring of victims, who approach the cells for support. Below is an instance of how an ASHA worker followed up with a victim, and how she has been offered help. 

Kamlaben was physically and emotionally tortured by her husband and other members of her marital family as she could not bear a child. She was repeatedly sent to her natal home in Sidhpur. She approached Sidhpur hospital for treatment of excess menstrual bleeding which had continued for the past 1.5 months. On examination she was found to be five months pregnant. Kamlaben was not aware of her pregnancy – she believed she had regular periods. She was referred to the cell as the doctor noticed her to be a domestic violence sufferer. Kamlaben refused doctor’s advice of terminating the pregnancy and returned to her marital home. She refused to answer the counsellor’s calls as well. Concerned for her wellbeing, the counsellor asked ASHA worker from Kamlaben’s village to visit her and check on her. ASHA worker managed to convince Kamlaben to follow up at the hospital, accompanied her to the gynaecology clinic and the cell. As she intended to continue the pregnancy, the doctors prescribed her medicines to stop the bleeding. ASHA monitored her regularly and reported back to the counsellor (Case records, Sidhpur Cell). 

The Impact of Support Cells

The process of upward referral is still in its nascent stage. SWATI expects it to be established over another two to three years. Yet, already, one can see the benefits of involving ASHA workers in early detection and in referring cases to the cells. Six percent (37 of the 644) of the total cases registered over a period of January 2016 and May 2018 had been referrals from ASHA workers. In addition to early detection, the involvement of ASHA workers at all stages of the process to help women suffering from violence has proved the need to embed such support cells into the healthcare system. It has also raised awareness among communities about domestic violence and the support system available. 

SWATI believes that for the initiative to sustain, it is essential to have a demand for services as well as the availability of efficient and accessible services. The cells at three hospitals are at different stages of assimilation into the healthcare system. While all three cells are comparable in terms of the number of cases received, the cell at Radhanpur is better integrated with communities, as indicated by a high proportion of self-referrals, referral from communities, from community-level health workers, namely ASHA workers and ANMs.

Distribution of Referrals

Another indicator of the need for and satisfaction with the resolution—which is rooted in feminist principles of women’s autonomy, rights and justice—is the higher proportion of referrals from satisfied clients as well as a good number of women approaching cells for repeated instances of violence.   

The data with SWATI has shown that the duration of violence suffered before the woman approached the cell is much shorter for the second episode. The cell counsellors provide support to victims on multiple fronts, ranging from counselling, mediation, registering a case with police, and to accessing survivor support services, such as shelter home, helpline, and medical aid. The support group for women at the Radhanpur cell has been well-appreciated by women, and it has played a key role in the rehabilitation of some of the survivors. Below is a case study of a woman who attended a support group meeting, which has brought about a positive change in her life. 

Geeta wanted to separate from her husband and filed a court case for receiving maintenance. The counsellor discussed with Geeta the need for her to become financially independent. The counsellor invited Geeta to attend a support group meeting. She heard the discussion and took inspiration from the women who had managed to turn their lives around. From a neighbour, she learnt the art of making doormats from old sarees and sells them for Rs 50/- a piece. Geeta attributes the change in her life to the support group meetings (Counsellor Notes from Support Group meeting).

The women who approach cells at the three hospitals have reported that they are accessible. Often, the victims of domestic violence, who experience restricted mobility, are generally allowed to access healthcare systems for themselves and their children. Therefore, they can travel to hospitals, and there lies a scope to approach the cell. 

Challenges Ahead

The initiative of SWATI to combat domestic violence is not without challenges. There is a need for a policy from the government to prioritise domestic violence against women as a health issue, and should work towards the development of protocols for screening, recording, and referrals for the same. As it has emerged from our understanding, despite the bright side of involving ASHA workers in combating violence against women, there have been several instances where both the women and ASHA workers have faced threats from communities and families. This calls for the sensitisation of other primary healthcare functionaries to create a support network for ASHA workers. There is also a need to sensitise doctors at all levels of the system to improve the results of the initiative. The active involvement of nursing and other staff at hospitals is also crucial for the sustainability of the initiative.  

The Way Forward

The experience of SWATI has proved the efficacy and the feasibility of establishing a rural hospital-based model to combat domestic violence. It has also indicated that such a model can be replicated in diverse settings. The preliminary experience so far has indicated the tremendous advantage of actively involving ASHA workers to detect domestic violence cases early, and to refer the victims to hospitals. Going forward, to consolidate the initiative into a self-sustained model, there is a need to ensure that domestic violence is considered as a public health issue.