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 Impact of the COVID-19 Pandemic and Lockdowns on Self-Poisoning and Suicide in Sri Lanka: An Interrupted Time Series Analysis.

Evidence from high-income countries suggests that the impact of COVID-19 on suicide and self-harm has been limited, but evidence from low- and middle-income countries is lacking. Using data from a hospital-based self-poisoning register (January 2019-December 2021) and data from national records (2016-2021) of suicide in Sri Lanka, we aimed to assess the impact of the pandemic on both self-poisoning and suicide. We examined changes in admissions for self-poisoning and suicide using interrupted time series (ITS) analysis. For the self-poisoning hospital admission ITS models, we defined the lockdown periods as follows: (i) pre-lockdown: 01/01/2019-19/03/2020; (ii) first lockdown: 20/03/2020-27/06/2020; (iii) post-first lockdown: 28/06/2020-11/05/2021; (iv) second lockdown: 12/05/2021-21/06/2021; and (v) post-second lockdown: 22/06/2021-31/12/2021. For suicide, we defined the intervention according to the pandemic period. We found that during lockdown periods, there was a reduction in hospital admissions for self-poisoning, with evidence that admission following self-poisoning remained lower during the pandemic than would be expected based on pre-pandemic trends. In contrast, there was no evidence that the rate of suicide in the pandemic period differed from that which would be expected. As the long-term socioeconomic impacts of the pandemic are realised, it will be important to track rates of self-harm and suicide in LMICs to inform prevention.

Barriers to help-seeking from healthcare professionals amongst women who experience domestic violence - a qualitative study in Sri Lanka.

BACKGROUND: Domestic violence (DV) is a major global public health problem which is associated with significant adverse consequences. Although Sri Lankan women who experience DV receive treatment from healthcare professionals (HCPs) for DV related physical and psychological problems, disclosure of DV within health services is quite low. This study explored barriers to disclosure of DV to HCPs among Sri Lankan women who experience DV. METHOD: This qualitative study took place in the Central Province of Sri Lanka. Twenty women who had experienced DV were recruited from Gender Based Violence Centers (Mithuru Piyasa Centers) and a toxicology unit of the two selected hospitals. Participants were purposefully selected using maximum variation sampling technique. In-depth interviews were conducted until data saturation was reached. Interviews were recorded, and analyzed using thematic analysis. RESULTS: Survivor related barriers to help seeking included women's lack of knowledge and perceptions about the role of HCPs, lack of confidence in HCPs, fear of repercussions, personal attitudes towards DV, and their love and loyalty towards the perpetrator. Women preferred it if HCPs initiated discussions about DV, and they valued it when HCPs could be confidential and protect their privacy, and give enough time for DV related issues during consultations. A perpetrator related barrier was the controlling behavior of the perpetrator. Social stigma and social and cultural norms about the role of women emerged as the socio-cultural constraints to disclosure. CONCLUSIONS: Barriers to help seeking for DV from HCPs exist at individual, healthcare level, and societal level. Community programs are needed to increase women's access to healthcare services and interventions should be implemented to develop effective, preventive, and supportive strategies at the healthcare system level.

Clinical and psychosocial factors associated with domestic violence among men and women in Kandy, Sri Lanka.

Domestic violence (DV) is a violation of human rights with adverse intergenerational consequences on physical and mental health. Clinical and psychosocial correlates of DV have been documented internationally, but evidence from South Asia is limited, especially among men. This is a nested cross-sectional study of the control population (N = 856) of a large case-control study in Kandy, Sri Lanka. Multivariable logistic regression models were conducted to estimate the association between clinical and psychosocial factors and experience of DV. Overall associations were examined and stratified by sex and type of abuse. Overall, 19% (95% CI 16%-21%) of the sample reported DV of any form in past year, with a similar prevalence being reported in both men (18% 95% CI 14%-22%) and women (19% 95% CI 15%-23%). Depression symptoms (adjusted OR [AOR] 3.28 95% CI 2.13-5.05), suicidal ideation (AOR 6.19 95% CI 3.67-10.45), prior diagnosis of a mental illness (AOR 3.62 95% CI 1.61-8.14), and previous self-harm (AOR 6.99 95% CI 3.65-13.38) were strongly associated with DV, as were indicators of perceived poor social support (AOR range 2.48-14.18). The presence of in-laws (AOR 2.16 95% CI 1.34-3.48), having three or more children (AOR 2.15 95% CI 1.05-4.41) and being divorced/separated/widowed were also strongly associated with DV (AOR 2.89 95% CI 1.14-7.36). There was no statistical evidence that any associations differed by sex. A multi-sectoral approach is needed to address DV in this context. Enhanced coordination between DV support services and mental health services may be beneficial. Further research and support for men as well as women is needed.

Hospital presentations for self-poisoning during COVID-19 in Sri Lanka: an interrupted time-series analysis.

BACKGROUND: There is widespread concern over the impact of public health measures, such as lockdowns, associated with COVID-19 on mental health, including suicide. High-quality evidence from low-income and middle-income countries, where the burden of suicide and self-harm is greatest, is scarce. We aimed to determine the effect of the pandemic on hospital presentations for self-poisoning. METHODS: In this interrupted time-series analysis, we established a new self-poisoning register at the tertiary care Teaching Hospital Peradeniya in Sri Lanka, a lower-middle-income country. Using a standard extraction sheet, data were gathered for all patients admitted to the Toxicology Unit with self-poisoning between Jan 1, 2019, and Aug 31, 2020. Only patients classified by the treating clinician as having intentionally self-poisoned were included. Data on date of admission, age or date of birth, sex, and poisoning method were collected. No data on ethnicity were available. We used interrupted time-series analysis to calculate weekly hospital admissions for self-poisoning before (Jan 1, 2019-March 19, 2020) and during (March 20-Aug 31, 2020) the pandemic, overall and by age (age <25 years vs ≥25 years) and sex. Individuals with missing date of admission were excluded from the main analysis. FINDINGS: Between Jan 1, 2019, and Aug 31, 2020, 1401 individuals (584 [41·7%] males, 761 [54·3%] females, and 56 [4·0%] of unknown sex) presented to the hospital with self-poisoning and had date of admission data. A 32% (95% CI 12-48) reduction in hospital presentations for self-poisoning in the pandemic period compared with pre-pandemic trends was observed (rate ratio 0·68, 95% CI 0·52-0·88; p=0·0032). We found no evidence that the impact of the pandemic differed by sex (rate ratio 0·64, 95% CI 0·44-0·94, for females vs 0·85, 0·57-1·26, for males; pinteraction=0·43) or age (0·64, 0·44-0·93, for patients aged <25 years vs 0·81, 0·57-1·16, for patients aged ≥25 years; pinteraction=0·077). INTERPRETATION: This is the first study from a lower-middle-income country to estimate the impact of the pandemic on self-harm (non-fatal) accounting for underlying trends. If the fall in hospital presentations during the pandemic reflects a reduction in the medical treatment of people who have self-poisoned, rather than a true fall in incidence, then public health messages should emphasise the importance of seeking help early. FUNDING: Elizabeth Blackwell Institute University of Bristol, Wellcome Trust, and Centre for Pesticide Suicide Prevention. TRANSLATIONS: For the Sinhalese and Tamil translations of the abstract see Supplementary Materials section.