Gender Violence:The Health Impact – Training Health Workers to Respond to GV – The Dilaasa Model

by Rashi Vidyasagar

World over, gender based violence has been accepted as a public health issue. As per the World Health Organisation (WHO), “The principles of public health provide a useful framework for both continuing to investigate and understand the causes and consequences of violence and for preventing violence from occurring through primary prevention programmes, policy interventions and advocacy.” This is because violence has severe physical and mental health consequences – both short term and long term, which includes bruises, cuts, and wounds, lacerations to depression, anxiety, nightmares, pregnancy, STIs, HIV, and even, death. All of these require a visit to the health facility where if proper care and treatment is provided, the survivor can begin the process of healing. Moreover, there is evidence to show that women are more likely to visit a hospital after an episode of violence rather a police station or a counselling centre.

Interventions carried out at the public health level (individual as well as community) can help mitigate violence and help deal with its consequences. However, medical professionals are ill- equipped to sensitively respond to the issue of violence against women. Lack of training and education on this issue, general indifference to dominant societal norms that legitimise violence against women are only some of the reasons for the inability of the professional to respond effectively to the needs of victims of violence. There is evidence that, even when women facing violence are identified within the health care system, providers have a tendency to focus on the physical consequences of abuse, to be condescending and distant, and to blame women for the violence they face. [Campbell and Lewandowski 1997; Kurz and Stark 1988; Layzer et al 1986; Vavarro et al 1993; Warshaw 1989, Daga 1998]. Within the medical context, violence is understood as a social problem and/or private family matter, as it does not fit into the traditional illness model. As noted elsewhere, “The concern for violence is conspicuous by its virtual absence in medical discourses. The special medical needs and rehabilitation of victims and survivors of violence are hardly ever discussed by doctors” (Jesani 1995). Thus, training becomes an integral part of any intervention with the health care system to fill the void left by the medical education.

It was with this view that Dilaasa, a hospital based crisis center was set by Municipal Corporation of Greater Mumbai (MCGM) in collaboration with CEHAT. Today, Dilaasa is a fully functional department within a 400+ bed hospital in the heart of Mumbai.

When CEHAT did the need assessment while setting up Dilaasa, a hospital based crisis centre in 2001, the need to develop a training module emerged clearly. This training was not only for doctors but also for hospital administrators, nurses and every health care professional. Between 2001 -2003, a module of adult peer to peer learning was created. A mixed group of doctors and nurses were selected with the hope that they would go on to train their own cadre. Despite this, referrals were low. This prompted the need to have continuous training of all medical professionals rather a one-time training. In 2006, Dilaasa started expanding and more and more health care providers were interested in providing services, however, the current healthcare system was not able to sustain their interest. It was then when it was decided to set up a training cell. It was formed to share resources and experiences of HCPs dealing with domestic violence, as well as provide them with formal roles of trainers with the aim of mainstreaming the training cell in the current health system.

The impact of this training can be seen in the steady growth of referrals by the health system. Along with training, it was also essential to give certain information-education-communication (IEC) material to these health care providers to supplement their referrals. Visiting cards, brochures, posters, pamphlets with messages of how violence is not their fault or that suicide is not the way out were printed. All of these were displayed prominently in the hospital or given to the doctors. It was realised that doctors don’t necessarily ask women patients about abuse in the OPDs. Women who reported abuse were being referred but no effort was made to draw out those who may have been abused but did not report it. That is when checklists of health consequences for each department and how could they ask about violence were printed and placards were made.

In the 14 years that Dilaasa has been functioning in a public hospital, training has been the cornerstone of the work that is being done. Continuous training with the hospital staff gives them a sense of identification and association with the project. The role of a medical professional is to identify, document and refer a survivor of violence. There should be no ambiguity in the expectations from the training. Training can provide tools that are required to identify the abuse and can also provide an important document if the woman takes the legal road. However, for the provision of comprehensive healthcare, this needs to be supplemented by a counselling centre where the doctors can refer the woman and/or organisations that provide services like shelter, counselling and legal aid to the survivor.

The following case study shows the importance of training all the hospital staff to recognise signs of abuse

Amma was referred to the Occupational Therapy Physiotherapy (OTPT) department by the orthopaedic department for the injuries that she had sustained. Amma had reported that she had fallen and hurt herself. At the OTPT she had received therapy for her hand and shoulder for a week. During this period, the physiotherapist found time with her alone and told her about Dilaasa and what it does. She then asked her if she would like to go there. Amma said, “No, I do not need it”. The following day, the physiotherapist asked her how she had sustained her injuries. Amma repeated the same story about a fall. The physiotherapist suspected abuse but did not want to probe further as she feared that the woman might not come back for treatment. She then asked one of the Dilaasa counsellors to come to OTPT department and speak to her. Amma then talked about the abuse she had suffered and subsequently sought Dilaasa services

Amma’s story is a testimony to the effect that training can have. Since 2001, Dilaasa has responded to over 3000 women, most referred by health care professionals. This has been possible through continuous support of the hospital staff, the trainers and the administrators who have ensured that a comprehensive health care response to survivors can be provided.

More information on setting up Dilaasa, the process of training the health care providers and other work related to Domestic Violence and Sexual violence can be found here: http://cehat.org/

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Rashi Vidyasagar is a Criminologist who is currently engaged in research on issues around violence against women including domestic violence and sexual assault. She is a Crisis Interventionist who works with CEHAT (Centre for Enquiry into Health and Allied Themes) in Mumbai.