On paper, most countries in the World Health Organization (WHO) European region have committed to tackling violence against women. Almost 90% of them have “multisectoral strategies” to address the issue and 75% have committed to train health workers. The reality on the ground, however, is different.

A recent WHO report found that less than a third of countries in the region offer basic care like clinical enquiry to identify intimate partner violence, emergency contraception, and HIV post-exposure prophylaxis to survivors of violence against women. Referrals to services in other sectors only exist in 47% of country policies while abortion is only included in 13%.

This comes while 30% of women aged 15-49 years in the WHO Europe region have experienced physical and/or sexual violence from intimate partners, and 10% have experienced nonpartner sexual violence.

Multisectoral plans and frameworks alone aren’t enough, Melanie Hyde, LLM, gender equality, health equity, and human rights technical officer at WHO, Europe and report author, told Medscape News Europe. To transition political commitment into action, she said, these plans need to be integrated into health sector-specific policies.

But it isn’t just policies that need to change. Structural changes spanning education to provision of care — and funding across the board — need to be in place for meaningful progress, health authorities and researchers told Medscape News Europe.

Educating the Doctors

“We’ve made significant progress in medical education in terms of the social determinants of health. But we have not made the same progress in understanding that violence, just like water and sanitation, is a critical public health issue,” Nata Duvvury, established professor and director of the Centre for Global Women’s Studies at the University of Galway, Galway, Ireland, told Medscape News Europe.

Duvvury noted that while education on violence against women is being introduced in Ireland, it is not yet at the level where general practitioners (GPs) can fully respond to all the potential dangers that women may face. While basic training, often conducted online, is mandatory, more advanced training is optional, she added.

“Training is reduced to a checklist with five modules you must take. You check them off and then it’s done, and it’s never really repeated. There’s no checking,” she said, adding that current methods don’t test whether clinicians have truly absorbed information or whether they can apply it in a given situation.

These issues, she said, could be improved by making advanced and refresher training mandatory, and conducting training in person to ensure formative dialogue takes place. Another important thing, she stressed, is that curricula are codesigned with survivors.

Looking for Survivors — Systematically

Systematic screening among pregnant women and new parents is another area with the potential to improve survivor care, Ditte Søndergaard Linde, PhD, associate professor in the Department of Clinical Research at the University of Southern Denmark, Odense, Denmark, told Medscape News Europe.

In a recent study, Linde and colleagues investigated the use of intimate partner violence screening among pregnant women in Denmark and Spain. Altogether, 8.5% of women in Denmark and 17% in Spain reported exposure to violence or severe conflicts.

In Denmark, screening involved an online questionnaire asking about physical, emotional, and sexual violence as well as relationship conflicts that pregnant women filled in before their first appointment with a midwife, said Linde. The midwife then followed up on the screening result and offered supportive interventions.

Marieke Liem, PhD, professor of security and interventions at Leiden University, Leiden, Netherlands, told Medscape News Europe that healthcare professionals should also look for more subtle signs of coercive control that may fall outside traditional clinical checklists.

Focusing on physical injury means that coercive patterns, such as multiple pregnancies in quick succession, a partner always accompanying the patient, or subtle restrictions on mobility or work, go unnoticed, she said.

“A simple opening question can help: ‘Are you ever afraid of your partner?’ If the answer is yes, it is important to follow up with concrete questions that address known high-risk indicators, such as whether the patient has ever been choked, forced into sex, or threatened with harm,” said Liem.

“Asking about these issues directly can be lifesaving as nonfatal strangulation in particular is one of the strongest predictors of femicide,” she said, adding that similar questions and pattern-spotting should be embedded into routine risk assessment and care pathways.

Users of Violence

Another area that receives relatively little attention but could make a big impact, said Linde, is support for persons who use violence but would like to stop.

“Persons who use violence are often very stigmatized. Many do not wish to use violence but do not have the strategies to control anger or behave in heated situations,” she said.

Linde is part of an ongoing EU project that has mapped screening tools and guidelines for persons who use violence in Europe. While the group has found screening tools, they have yet to find guidelines.

“My overall opinion is that this is definitely an area that needs more attention,” she said, noting that some level of support already exists for such people in Denmark and Verona, Italy.

Fragmentation

Lack of communication between services is another key bottleneck for addressing violence against women, according to Liem.

“Different parts of the system see different pieces of a survivor’s situation: the GP sees fatigue and unexplained pain, mental health services may treat trauma or a partner’s psychiatric problems, and debt counselors address financial stress — but rarely is this information integrated. Without a coherent, shared approach and shared definitions, crucial signals get lost,” she said.

To solve this problem, she recommended the creation of “genuine cross-agency coordination” among health providers, police, social services, and justice systems. This, she said, would mean the use of compatible registration systems, shared definitions, and consistent risk indicators.

“When each service uses its own terminology or data structure, patterns of escalating danger get lost,” she said.

While Netherlands does not yet have such an integrative system, Filomena, a domestic violence organization in Rotterdam, Netherlands, is an example where an integrative approach gives women access to psychologists, forensic examiners, lawyers, social workers, and more. This, said Liem, allows women, as opposed to institutions, to be the central point of gravity.

Duvvury, Liem, and Linde reported no relevant financial relationships.

Annie Lennon is a medical journalist. Her writing appears on Medscape.co.uk, Medical News Today, and Psych Central, among other outlets.