ABSTRACT

Background and Objective:

Domestic violence (DV) has been identified as a very serious problem that affects women and children at all levels of society, regardless of race, financial status, religion, and level of education. DV in Pakistan is a very sensitive issue keeping in mind the psychological, religious, and social aspects. The aim of the study was to assess the level of knowledge and perception about DV amongst gynecologists working in the tertiary care teaching hospitals of Lahore city, Pakistan.

Methods:

It was a cross-sectional survey study carried out among the doctors working in the Gynecology departments in different tertiary care teaching hospitals of Lahore from July to August, 2021. A total of 154 doctors of the Gynecology departments participated in this study.

Results:

Most of the participants (53.4%) had suboptimal knowledge regarding the screening tools for DV against the women reporting in Gynecology clinics from July to August, 2021. A significant association was found between awareness regarding DV and an agreement for introducing a formal training course (p < 0.05).

Conclusion:

The knowledge and perception of health care providers to screen the cases of DV is the basic key to identify such victims. However, a proper training of the staff handling such patients needs to be implemented at government level.

Keywords:

Domestic violence (DV), intimate partner violence (IPV), knowledge, perception, training, workshop, gynecologists.

Introduction

Domestic violence (DV) has been identified as a very serious problem that affects women and children at all levels of society, regardless of race, financial status, religion, and level of education. It is a widespread, deeply ingrained evil, which has a serious impact on women’s health and wellbeing.¹ This violence may cause physical, sexual, and emotional harm to the victim, which may contribute to other adversities in the family and society.²

Globally, one in every three women experiences physical and/or sexual violence in their lifetime.³ No country is immune to devastating physical and emotional effects of violence. The World Health Organization reports on violence and health defines intimate partner violence as “any behavior within an intimate relationship that causes physical, psychological, or sexual harm to those in the relationship.”⁴

DV in Pakistan is a sensitive issue. Besides misinterpretation of the religious context, other cultural and traditional factors may affect the understanding of violence in the family. Pakistani women often experience several forms of abuse. Besides the most common forms of abuse (sexual, emotional, and physical), women also experience economic abuse through the deprivation of education, work, and inheritance. The combination of these forms of abuse has resulted in the deprivation of important rights for women in Pakistan.⁵

There are several barriers to the study of DV in Pakistan including societal structure, the high value of family privacy, and lack of reporting of abuse cases.⁶ From a legal perspective, abused women often face obstacles when seeking help for violence. In 2012, the government of Pakistan issued the first law that criminalized DV in an attempt to illuminate the issue of family violence. The Protection from Abuse Act criminalizes “all acts of gender-based and other physical or psychological abuse committed by a respondent against women, children or other vulnerable persons......” “It shall not be less than 6 months and with fine which may not be less than 100,000 rupees.”⁷

Lack of knowledge is a crucial barrier to actual screening for DV. In addition, considering violence as a stigma in our society makes it difficult to screen and report such cases of violence. The knowledge and perception of health care providers to screen the cases of DV is the basic key to identify such victims. However, there is a big question mark for the level of training of health care providers to screen DV and to identify battered women.⁸ All these problems hinder and disrupt or prevent screening.

Doctors working in the Gynecology departments are the ones dealing with such victims of DV most frequently. Their knowledge and perception to pick the cases of DV is the basic key. But here the question arises, are these doctors aware of the way to screen cases of DV? Do they have appropriate training to screen the cases of DV? The level of knowledge and perception of gynecologists is considered to be the first barrier in the screening of DV. It is the need of the time to appropriately train these doctors to identify and manage such cases.^9,10,11 Furthermore, there is a need to keep the data of all the identified cases of violence at the regional level to see the effectiveness of all the implementations both at the society and government level.

The present study was conducted to determine the knowledge and perception regarding DV against women among the doctors working in the Gynecology departments of various tertiary care teaching hospitals. It also aimed to determine the different ways to improve their knowledge and perception of DV.

Methods

It was a cross-sectional study carried out among 154 doctors working in the Gynecology departments in different tertiary care teaching hospitals of Lahore from July 26, 2021 to August 30, 2021. These doctors included house officers, trainees, senior registrars, Assistant Professors, and Associate Professors. The study was approved by the ethical committee of the hospital. It was a customized questionnaire made with the censuses of authors of the article and validated by the senior gynecologists working in the hospital.

A questionnaire was distributed among all the participating doctors among different hospitals of Lahore for the data collection (Lahore General Hospital, Services Hospital, and Jinnah Hospital Lahore). All the participating doctors were briefed about the study and informed consent was taken from each participant. A confidential and anonymous written survey was conducted. The survey had three components. The first part was about the demographic details, including the age categories (<25, 25-30, 31-35, and >35 years), gender, marital status, qualification, working designation, and hospital affiliation without ward number. The second part was to be filled by the doctor without any instruction or formal training given to them, in order to know their basic level of knowledge and perception about DV against women. The third component related to the ways to improve the knowledge and perception about DV. All proformas once filled were returned to the corresponding author.

Statistical analysis

Data were entered and analyzed in IBM Statistical Package for the Social Sciences version 25.0. Descriptive analysis was done to find out the frequencies and percentages of all the variables. Pearson Chi-square test was used to compare the significance between different variables. The level of significance was 0.05.

Results

A total of 154 questionnaires were filled and analyzed for this study. Most of the respondents (85, 55.2%) were in category of 25-30 years of age. Most of the respondents (94, 61%) were married, and (78, 50.6%) were only MBBS and the rest were of higher order qualifications. Out of 154, 151 participants (98.1%) were Pakistanis. A total of 81 participants (52.6%) were residents/trainees and 141 (91.6%) were females. Most of the respondents (74, 48.1%) belonged to Jinnah Hospital Lahore, Pakistan (Table 1).

A total of (82, 53.2%) participants did not know of the screening tools for DV during pregnancy while only 47 respondents (30.5%) were aware of this practice. Most of the respondents (109, 70.8%) knew about the law for DV. On the other hand, only 33 respondents (21.4%) knew about the helpline numbers for DV, 52 respondents (33.7%) knew about the online applications for DV. In addition, 74 (48.1%) respondents knew about the Government or private protection centers or shelters for women suffering from DV (Table 2).

Regarding the types of DV common women face, out of 154 respondents (66, 42.8%), strongly agreed for the physical violence, while 48 respondents (31.2%) strongly agreed for verbal violence, 66 respondents (42.9%) strongly agreed for women threatened with harm, and 53 respondents (34.4%) strongly agreed for emotional/psychological violence on women. So, other than physical assault, they have doubts about the other screening component of DV (Table 3).

Most of the respondents 105 (68.1%) were not satisfied with their knowledge regarding screening of DV. Eighty one respondents (52.6%) had diagnosed at least a single case of DV during their clinical practice. Out of 154 respondents, 118 (76.6%) were aware of DV from their medical curriculum during the medical study, 112 respondents (72.7%) from extra-curricular activity, 119 respondents (77.3%) from professional experience (practice), 105 respondents (68.2%) from personal experience, 120 respondents (77.9%) from literature and books, and 141 respondents (91.5%) got their knowledge from media (Table 4).

Table 1. Demographic variables of the participants (154).

When the doctors were further questioned about the usefulness of relevant training courses and workshops, 67 respondents (43.5%) agreed that students must know about the real definition of DV, 71 respondents (46.2%) agreed about clarity on the background facts and information, 70 respondents (45.5%) agreed for more emphasis on the clinical features associated with DV and 71 respondents (46.1%) agreed that assessment questions must be included in the course respectively. Most of the respondents (69, 44.8%) agreed that the key aspect of history taking must be included in the course. Another 70 respondents (45.5%) agreed that the advice on accurate record-keeping, legal overview, and review of safety issues must be included in the course of medical students. Lastly, 78 respondents (50.6%) agreed that information about community agencies must be a part of a DV course (Table 5).

A significant association was found between agreement for formal course on DV among the gynecologists with respect to awareness about DV was seen. (p-value = 0.00). However, there was no significant association between other parameters (Table 6).

Discussion

DV against women in Pakistan is a very sensitive issue keeping in mind the psychological, religious, and social aspects. Furthermore, a male-oriented society and lack of support to the female victims make the condition more badly. According to a study carried out by the “Human Rights Watch,” the estimated violence against women in Pakistan is 10%-20%.¹² Furthermore, a survey carried out by the “Thomson Reuters Foundation” showed that Pakistan has been graded as the third most dangerous place for women in the world.¹³ All these figures highlight the severity of DV in Pakistan.

Globally, gynecologists are the mainstream dealing with the female patients exclusively and they are often very close to them. Hence, their level of awareness matters the most to diagnose and help victims of DV.¹⁴ When these doctors were questioned about how they screen for DV, the answer was very devastating as the majority were not aware of the fact that how to screen for DV, comparable to the results found in the study of Ben Natan et al.¹⁵

In the present study, the Hurt-Insult-Threaten-Scream (HITS) tool was used to assess the health care professional’s knowledge for the screening of DV which is recognized since 1998.¹⁶ HITS tool is short and brief and can easily be used to evaluate and explore DV even in the busy Gynae clinics. Majority of gynecologists strongly agree with the physical component of the HITS screening tool. Two-third of them were aware of one of the major components of a screening tools for DV. Physical abuse is considered to be a form of DV by the majority of gynecologists, but there was a conflict for the other components among these gynecologists, e.g., verbal or emotional.

Two-third of gynecologists were aware of the fact that there is a law against DV in Pakistan. As the study in South Korea has shown that there is a relationship between the awareness of law against DV and its incidence. More the awareness is, the lesser would be the incidence.¹⁷

Once diagnosed with the victims of DV, the major issue is what to do next? How to guide such patients of DV further and where to report and refer these patients? The level of awareness of the gynecologists about the helpline number, online app, and available shelter houses and protection centers by the government of Pakistan was poor; similar results were found in the study carried out among UK primary healthcare clinicians.¹⁸ Hence, even if they diagnose few cases of DV by their clinical experience but what to do next is a big question. The dilemma is that if this is the level of awareness of gynecologists, what would be the level of the general population?

Table 2. Awareness regarding DV

Table 3. Perception of DV

SD = Strongly disagree, DA = Disagree, N = Neutral, A = Agree, SA = Strongly agree.

Table 4. Level of knowledge regarding DV.

The health care system is often considered to be a poor source for the awareness of DV. The majority of the doctors in a study were not satisfied with their level of awareness regarding this subject.¹⁹ They agreed that they got some of the information about DV from their medical school. Other sources also include workshops and conferences. But in the majority of cases, the main source was the media.

The results highlighted the need to give some light to this sensitive issue. It requires not only to diagnose but also to improve the ways to properly manage such cases by the gynecologists.²⁰

There was a unanimous agreement by the gynecologists that the first step of prevention of DV is proper training of the staff handling such patients. It includes workshops, courses, and conferences for health care practitioners. The training may include not only proper ways to diagnosing but also an orientation about the further steps to be taken after recognition of a victim.²¹ Appropriate awareness programs including workshops, conferences, training courses should be conducted not only for doctors but also for the general population so that they can pick and help the DV victims.²²

Table 5. Agreement for a formal DV course in undergraduate studies

SD = Strongly disagree, DA = Disagree, N = Neutral, A = Agree, SA = Strongly agree.

Table 6. Comparison between different variables with respect to awareness of DV

a = insignificant, b = significant

Conclusion

Lack of knowledge is a crucial barrier to actual screening for DV. The knowledge and perception of health care providers to screen the cases of DV is the basic key to identify such victims. The first step of effective screening of DV is the proper training of the health care providers handling such patients.

Limitations of the Study

The limitation of this study is inclusion of only one city, Lahore. More data from all over the Pakistan, especially from other constrained provinces would be generalizable to the women of our community. Also, intervention could not be adopted to appraise the pre-and post-intervention level of knowledge and perceptions among the participants.