Asking women about gender-based violence can seem daunting to many health care providers. Many might ask: Why would women want to talk to me about their experiences of violence? What can I do to help? Should I open up the topic if I can’t deal with the root of the problem? These are just some of the doubts that providers have when they consider incorporating screening and services for victims of violence into their programs.

Changing providers’ beliefs, attitudes and knowledge is an essential—and perhaps the most important—component of improving the health sector response to gender-based violence. Routine screening policies will fail if health programs do not build support among staff for this endeavor. Providers’ resistance to screening, particularly among physicians, has been reported in many different settings. In some cases, this resistance is based on misconceptions and prejudices. In other cases, their concerns are legitimate and need to be addressed by making changes within health services. In fact, there are many things that program managers can to do overcome resistance and ease providers’ concerns.

Typical providers' concerns about screening and recommended strategies for addressing these concerns

Typical reasons why providers do not want to screen women for gender-based violence:

Time Concerns: Many providers are under pressure to see many clients in a short amount of time. Providers may be concerned that they do not have time to raise an additional issue with their clients. They may also be concerned that if a woman says “yes” to a screening question, they will have to spend extra time providing emotional support or following up with referrals.

What program managers can do to address providers' concerns :  

• Ensure that screening and referral protocols are as efficient as possible.
• Assign screening to staff who will not be overburdened by the responsibility.
• Encourage providers to screen some clients. They may find that screening takes less time than expected. In fact, one study found that asking women three brief questions correctly identified the majority of abused women and took an average of just 20 seconds.
• Show providers evidence linking violence with repeat visits and increased use of health services. If they understand the extent to which violence is the underlying cause of many chronic health problems, they may recognise the potential screening to improve the quality of care they provide, as well as to save time in the future. (However, this may not help provider who are paid by the number of consultations they provide).
• Consider training other staff to provide immediate attention that victims may need. For example, if physicians are screening, consider training counsellors or nurse to offer safety planning and crisis intervention to women who disclose violence. Having backup support may ease physicians' concerns about time constraints.
• Consider ways to ease time pressures on providers more generally.

They do not consider it a health issue:  Many providers do not recognise the health consequences of violence, or they believe that other health issues should have higher priority. In many cases, they believe that the issue of violence belongs in the realm of social work or psychology.

What program managers can do to address providers' concerns :  

•  Educating staff about the health consequences of violence may change their opinion about whether this is an issue that is worth their time.
• Share research that suggests that violence against women is just as prevalent as many common conditions for which providers routinely screen.
• Educate providers about the potential role that the health sector can play in addressing gender-based violence.

They believe women will deny it and/or feel ashamed: Providers believe that women do not want to be asked about violence, that they feel it is a private matter, that they will feel ashamed to talk about it with their health care provider, and/or that they will deny it.

What program managers can do to address providers' concerns :  

• Share research that suggests that just the opposite is true. Many women who experience violence (and even those who don't) want to be asked and say that health providers are the people with whom they would like to discuss the issue.
• Encourage providers to screen a few clients. They may be surprised at how readily women disclose experiences of gender-based violence, even sensitive types of violence such as sexual abuse in childhood.
• Sensitize providers about their own potential to reinforce the message that violence is not a private matter; It is not the victim's fault; It is not a reason to be ashamed; it is not acceptable; but it is a serious health risk. Women in the IPPF Western Hemisphere Initiative told evaluators that providers helped them realise that their health was at risk and that they were not at fault.

They believe that it does not happen to their clients: Some providers who serve affluent clients believe that gender-based violence only happens to poor or uneducated women.

What program managers can do to address providers' concerns :  

• Share research that indicates that gender-based violence is prevalent among all socio-economic levels.
• Encourage providers to screen a handful of clients. They are often surprised at the prevalence levels they find even among affluent clientele.

 They believe that most of their clients have experienced violence: Depending on the type of screening questions used, provides may have a legitimate concern that so many clients have experienced violence that screening will generate an overwhelming demand for assistance.

What program managers can do to address providers' concerns :  

• Conduct research among the clinic population to find out how prevalent certain kinds of violence are, and share this data with providers.
• Ensure that the health programs has resources to meet the demand that might be generated by screening.
• Develop triage strategies for getting services to women most at risk.
• Consider strategies for reducing levels of violemve in the wider community, such as education campaigns.

 They believe that men have the right to discipline their wives and/or to expect sex on demand: In some cases, providers believe that violence is just a normal and acceptable part of life in their community.

What program managers can do to address providers' concerns : 

• Use an evidence-based approach to increase providers' understanding of gender-based violence as a public health problem and a human rights violation.
• When providers continue to express negative attitudes toward victims of violence, do not require or even encourage them to screen.
• If some providers' attitudes do not change over time, it may be necessary to ask them to leave the organisation.
• Consider assessing such attitudes when hiring new staff members.

They believe that they cannot do anything to help victims of violence: Many providers  feel that they cannot offer women any effective assistance, and therefore feel it would be unethical to screen for gender-based violence. This is a reasonable concern that health programs need to take seriously.

What program managers can do to address providers' concerns : 

• Share evidence that while doctors cannot "solve" the problem of gender-based violence alone, they can provide a critical opportunity for detection and referral.
• Build networks with referral systems and give providers referral directories to services outside the clinic.
• Consider developing services for victims of gender-based violence within the organisations.
• Share evidence suggesting that the simple act of asking women about violence in an empathetic manner can let victims know that violence is an important medical problem and that it is not their fault.
• Educate providers about how knowing a client's current or past history of violenve may help improve the quality of providers' work by improving their ability to accurately diagnose and determine the best course of treatment.
• Share what other providers have to say about their experience with screening. For example, Leigh Kimberg, MD, who screen for gender-based violence at a San Francisco public health clinic says, "Since I cannot rescue victims, I realise all I need to do is be empathetic and supportive, and this simple intervention can really help empower someone".
• Sheare information about women's own perspectives regarding the benefits of screening, which in many settings has been quite positive.

They believe that they are not trained to determine who is a "real" victim of violence: Some providers think that for some reason, only psychologists are professionally equipped to identify who is a victim of violence and who is not.

What program managers can do to address providers' concerns : 

• Ask providers to screen a handful of women. As soon as they hear their own clients speaking about their experiences of violence, providers tend to forget (almost immediately) any concern about whether someone is "really" a "victim" and what it means for screening data to be "valid" or "reliable"
• In some cases it may be helpful to dispel the misconception that a significant proportion of rape victims lie. This is a common prejudice in some parts of the world, and may contribute to the belief that only a psychologist can reliably identify who is and is not a victim of violence.

They feel that it is unethical to screen women because there are no referral services in the community: This is a serious and legitimate concern for which there may not be an easy solution.

What program managers can do to address providers' concerns : 

• However, scarce referral services may be in the community, health programs beed to make every effort to research what few services may be available.
• Health programs can work to increase the types of referral services in the community by lobbying governments, law enforcement agencies, and other non-governmental organisations.
• Health programs can consider setting up services within the health program itself, particularly lower-cost strategies such as support groups.
• At the very least, health programs can ensure that staff are prepared to provide danger assessment, safety planning, counselling and crisis intervention before they begin screening.

They are concerned about getting involved in legal proceedings: Providers are sometimes concerned that it they ask about violence, they may end up having to testify in court. They may feel that this can be time consuming and may even put their physical safety at risk.

What program managers can do to address providers' concerns : 

• Research the local situation and ensure that providers have a basic understanding of when courts require medical evidence and what are their legal obligations with regard to victims of violence.
• Establish links with legal services for victims of gender-based violence in the community that can assist the health program in this area.
• Establish safety protocols to protect providers both whike they are in the clinic or off site. Recognise that providers' safety is a serious concern that warrants special policies and monitoring.
• Provide ongoing support to providers in case they do become involved in a legal proceeding.

Source: IPPF Western Hemisphere Region, 2004, Improving the Health Sector Response to Gender Based Violence: A Resource Manual for Health Care Professionals in Developing Countries.