Comparing health systems readiness for integrating domestic violence services in Brazil, occupied Palestinian Territories, Nepal and Sri Lanka.

Domestic violence (DV) is a global prevalent health problem leading to adverse health consequences, yet health systems are often unprepared to address it. This article presents a comparative synthesis of the health system's pre-conditions necessary to enable integration of DV in health services in Brazil, Nepal, Sri Lanka and occupied Palestinian Territories (oPT). A cross-country, comparative analysis was conducted using a health systems readiness framework. Data collection involved multiple data sources, including qualitative interviews with various stakeholders; focus-group discussions with women; structured facility observations; and a survey with providers. Our findings highlight deficiencies in policy and practice that need to be addressed for an effective DV response. Common readiness gaps include unclear and limited guidance on DV, unsupportive leadership coupled with limited training and resources. Most providers felt unprepared, lacked guidance and felt unsupported and unprotected by managers and their health system. While in Brazil most providers felt they should respond to DV cases, many in Sri Lanka preferred not to. Such organizational and service delivery challenges, in turn, also affected how health providers responded to DV cases leaving them not confident, uncertain about their knowledge and unsure about their role. Furthermore, providers' personal beliefs and values on DV and gender norms also impacted their motivation and ability to respond, prompting some to become 'activists' while others were reluctant to intervene and prone to blame women. Our synthesis also pointed to a gap in women's use of health services for DV as they had low trust in providers. Our conceptual framework demonstrates the importance of having clear policies and highlights the need to engage leadership across every level of the system to reframe challenges and strengthen routine practices. Future research should also determine the ways in which women's understanding and needs related to DV help-seeking are addressed.

The global prevalence of intimate partner homicide: a systematic review.

BACKGROUND: Homicide is an important cause of premature mortality globally, but evidence for the magnitude of homicides by intimate partners is scarce and hampered by the large amount of missing information about the victim-offender relationship. The objective of the study was to estimate global and regional prevalence of intimate partner homicide. METHODS: A systematic search of five databases (Medline, Global Health, Embase, Social Policy, and Web of Science) yielded 2167 abstracts, and resulted in the inclusion of 118 full-text articles with 1122 estimates of the prevalence of intimate partner homicide after double-blind screening. All studies were included that reported the number or proportion of women or men who were murdered by an intimate partner in a country, province, or town, using an inclusive definition of an intimate partner. Additionally, a survey of official sources of 169 countries provided a further 53 estimates. We selected one estimate per country-year using a quality assessment decision algorithm. The median prevalence of intimate partner homicide was calculated by country and region overall, and for women and men separately. FINDINGS: Data were obtained for 66 countries. Overall 13·5% (IQR 9·2-18·2) of homicides were committed by an intimate partner, and this proportion was six times higher for female homicides than for male homicides (38·6%, 30·8-45·3, vs 6·3%, 3·1-6·3). Median percentages for all (male and female) and female intimate partner homicide were highest in high-income countries (all, 14·9%, 9·2-18·2; female homicide, 41·2%, 30·8-44·5) and in southeast Asia (18·8%, 11·3-18·8; 58·8%, 58·8-58·8). Adjustments to account for unknown victim-offender relationships generally increased the prevalence, suggesting that results presented are conservative. INTERPRETATION: At least one in seven homicides globally and more than a third of female homicides are perpetrated by an intimate partner. Such violence commonly represents the culmination of a long history of abuse. Strategies to reduce homicide risk include increased investment in intimate partner violence prevention, risk assessments at different points of care, support for women experiencing intimate partner violence, and control of gun ownership for people with a history of violence. Improvements in country-level data collection and monitoring systems are also essential, because data availability and quality varied strongly across regions. FUNDING: WHO, Sigrid Rausing Trust, and the UK Economic and Social Research Council.

Sexual and reproductive health: a matter of life and death.

Despite the call for universal access to reproductive health at the 4th International Conference on Population and Development in Cairo in 1994, sexual and reproductive health was omitted from the Millennium Development Goals and remains neglected (panel 1). Unsafe sex is the second most important risk factor for disability and death in the world's poorest communities and the ninth most important in developed countries. Cheap effective interventions are available to prevent unintended pregnancy, provide safe abortions, help women safely through pregnancy and child birth, and prevent and treat sexually transmitted infections. Yet every year, more than 120 million couples have an unmet need for contraception, 80 million women have unintended pregnancies (45 million of which end in abortion), more than half a million women die from complications associated with pregnancy, childbirth, and the postpartum period, and 340 million people acquire new gonorrhoea, syphilis, chlamydia, or trichomonas infections. Sexual and reproductive ill-health mostly affects women and adolescents. Women are disempowered in much of the developing world and adolescents, arguably, are disempowered everywhere. Sexual and reproductive health services are absent or of poor quality and underused in many countries because discussion of issues such as sexual intercourse and sexuality make people feel uncomfortable. The increasing influence of conservative political, religious, and cultural forces around the world threatens to undermine progress made since 1994, and arguably provides the best example of the detrimental intrusion of politics into public health.