Routine screening, when done well, can be a powerful tool to raise women’s awareness that they deserve to live a life free of violence. Often many women living in situations of violence do not recognize their situation as “abuse” or “violence.” When women do not recognize that they can and deserve to live without violence, they rarely seek help spontaneously.

For a clinic to be ready for routine screening, clients’ privacy, safety, and confidentiality must be ensured, through:

• Consultation rooms where women cannot be overheard or seen from the outside 
• Secure storage areas for records 
• Policies about who has access to records and when providers are allowed to disclose client information 
• Well-trained staff with appropriate (supportive and nonjudgmental) attitudes and skills, who understand the risks that women face in the cycle of intimate partner violence

Developing written screening protocols:  It is important to involve providers during the protocol development process because routine screening may require changes to patient flow or clinic procedures, and because providers are ideally positioned to judge whether the protocol will be feasible and efficient. When writing a routine screening protocol, the health program needs to consider a number of issues for each step in the screening process:

1. Preparation of client charts to ensure that medical charts have the necessary paperwork for screening and documentation

Key considerations: 

• How to record answers to screening questions, i.e., on dedicated space printed or stamped onto the clinic history form, or a special registry, or additional specialized forms 
• Will the data system be manual or computerized or both? 
• Which staff member(s) (receptionist, nurse) will have the responsibility for this paperwork?
• When are staff are expected to fill the paperwork, i.e., on the day of the client’s appointment or all at one time

2. Screening by asking a series of direct screening questions to identify whether the client has experienced GBV.

Key considerations: 

• What types of services will implement routine screening – all services or only reproductive health services. 
• Which specific staff members (physicians, family planning counselors) will be responsible for routine screening and whether staff screen returning clients as well as new clients 
• At what point during the consultation will staff members screen women – at the beginning of the consultation, or after the clinical exam, when the woman meets with the physician (and is already dressed)?

Other main considerations are:

• The screening questions and danger assessment questions providers will use. 
• Health programs need to identify exactly what types of GBV they are going to address, and formulate working definitions of each category of violence, based on the local situation. Screening questions that correspond to the operational definitions of violence and make sense in the local language need to be formulated or adapted.

3. Document the results of screening and ensure that the results of screening are recorded in the client’s chart (or other registry)

Key considerations: 

• What kind of system are you going to offer to providers so that they can document cases of GBV?

4. Provide safety planning, emotional support and crisis intervention Key considerations: 

• Which staff members will be responsible for providing assistance with safety planning, emotional support and crisis intervention? 
• Protocols need to be developed to help staff care for women in crisis. 
• In addition to training, all staff to follow the written protocol, health programs need to discuss providers’ concerns and do everything possible to support staff in their effort to screen. Providers who routinely screen women for violence often experience frustration, fatigue, or other negative emotions unless the health program organizes ongoing support.

5. Provide a referral to other services (medical, legal, psychological, shelter, etc.)

Key considerations: 

• The program could provide a referral directory to all providers; print lists of services to hand out to clients; or alternatively 
• What services (counseling, psychological) within your institution can you provide to women who have experienced GBV, i.e., support groups for women, links to organizations that provide legal advice, etc.
• Can providers who refer women to services within the institution make the appointment for women directly, or does the woman herself have to do it? Are there any circumstances under which your staff would be willing to accompany women to an external referral, for example, to lodge a complaint at the local police station in cases of rape? 
• There also needs to be a system to document the referral. When adequate referral services in the community do not exist, all providers who screen should be able to handle a disclosure of violence in a sensitive and supportive way, and at least some staff in the clinic should be able to provide basic safety planning, crisis intervention, and information about legal issues. Providers should not refer women to agencies that put them at risk of additional harm.

6. Ensure that the client receives the services that she originally requested.

Key considerations: 

• The clinic must have a documentation system that providers use when they see signs of violence, but the woman says that she has not experienced GBV. 
• Does the clinic have resources to produce or obtain educational materials about EC? 
• Can the clinic explicitly incorporate issues related to GBV into protocols for providing family planning and STI/HIV counseling services?

7. Follow up cases of GBV to monitor the extent to which clients are able to access referral services and be treated well.

Key considerations:

• What systems for providing follow-up and monitoring are feasible given the resources of the clinic, the types of referral services available, the social context, etc? 
• Health programs should monitor and evaluate routine screening on an ongoing basis by gathering information on:
• Provider perspectives about how well the routine screening protocol is working and whether adjustments need to be made;
• Service statistics about screening levels, detection rates and referral numbers; and
• Women’s perspectives about the quality of care and the acceptability and benefits of screening.

Health programs must ensure that their efforts do not harm women or put them at greater risk of additional violence or trauma. Caring for survivors of violence is complex. There is much to be learned about how health programs can care for women in effective and ethical ways. Health programs that launch a poorly-planned routine screening policy, for example, may do more harm than good.

Remember the first principle of medicine is to do no harm. If health programs do not evaluate their work, they will not find out whether they have benefited women or caused them additional risk.

Adapted from: Improving the Health Sector Response to Gender-Based Violence: A Resource Manual for Health Care Professionals in Developing Countries, International Planned Parenthood Federation, Western Hemisphere Region 2004.