Background: The Nepal Demographic Health Survey 2016 found that 23 % of women 15-49 years had experienced physical violence, 12% emotional violence and 7% sexual violence from their husband; 6% experienced domestic violence (DV) during pregnancy. Gender-based violence has been incorporated into the national reproductive health agenda primarily at the policy level and partly at the health service levels, yet self-reporting and help-seeking remain uncommon. The ADVANCE study found that women are interested in sharing their experience with empathetic, non-judgmental and well-trained health care providers. A significant proportion of women attend antenatal care in rural areas; sexual and reproductive health care settings provide a window of opportunity for identifying and supporting women affected by DV.

Existing model: Safe and Sound is a brief, nurse-led, empowerment counseling intervention and active community referral for abused women attending antenatal care services, developed by WHO and WRHI in South Africa.

The aim of this study is to pilot an adapted Safe and Sound intervention within the outreach centers of Dhulikhel Hospital, to surface program theory and evaluate the process of incorporating Safe and Sound intervention in a Nepali context. As a secondary outcome, this study will assess whether the intervention results in a reduction in women’s experience of DV. A multi-level mixed methods approach will be used.

General objective: adapt and pilot test a health care provider-led brief counseling intervention (Safe and Sound) in outreach centers of Dhulikel hospital.

Specific objectives:

1. Explore outreach centres’ readiness to respond to DV, including health care providers’ perceptions of and response to cases of domestic violence (e.g. perceived barriers to providing care)
2. Explore the turning point of women who experience DV to decide help seeking
3. Explore the views of key stakeholders regarding the appropriate role of sexual and reproductive health in responding to domestic violence and elucidate a potential referral pathway
4. Validate the content of provider intervention measure to assess readiness among health care provider using DELPHI
5. Based on objectives 1-3,adapt and pilot an existing health care provider-led empowerment counseling intervention for women exposed to domestic violence who are receiving antenatal and sexual and reproductive health in the outreach community health centers
6. Surface program theory and evaluate the process of incorporating an adapted version of Safe and Sound intervention within outreach centers setting in Nepal.
7. Assess whether the counseling intervention improves the health and help seeking behaviors, safety, self-efficacy, women’s mental health and quality of life of abused women
8. As a secondary outcome (which may arise from enhanced safety)assess whether the intervention results in a reduction in women’s experiences of domestic violence.

Research progress:

Formative Phase

• HERA team prepared facility observation checklist and conducted facility observation at 10 outreach centers of Dhulikhel hospital to assess the readiness of the institution. In addition, we also conducted 9 IDIs with heath care providers to qualitatively explore their perception and readiness towards DV; quantitatively we collected Pre-PIM questionnaires from 10 outreach centers. The PIM questionnaires were validated through cognitive interviewing and cross cultural adaptation, its findings shared within the wider group of HERA and then the questionnaires were refined
• We also collected four FGDs each from female community volunteer and women’s group. Furthermore, we conduct IDIs with 6 survivors of violence to explore their turning point and help seeking behavior and 6KIIs were collected
• We conducted Rapid analysis of facility observation checklist, IDI of HCPs and selected 5 ORCs as our intervention sites (Baluwa, Bahunepati, Manekharka, Bolde & Kirnetar). This data also aided in designing the intervention
• In-depth analysis of KIIs and IDI with HCP, survivors as well as the FGDs is ongoing.

Intervention

• We formed a country level local advisory We conducted meetings with stakeholder to design the intervention together with them. We have conducted altogether three quarterly meeting with stakeholder during the formative and intervention stage. The first one was to form a local advisory committee, the second meeting to inform regarding the formative evidences, third one to co-design the intervention
• Initially we had planned SAFE and SOUND intervention. However, based on the findings from the formative phases and stakeholders meeting, we applied a gender transformative, survivor centered and trauma informed care approach to capacity strengthening of the health care providers in the five outreach centers and its adjacent government health posts and completed refresher trainings.
• In addition, we also worked towards building the capacity of the women’s group and FCHVs from 5 intervention sites.
• We developed an innovative questionnaire using a color-coded audio computer assisted self-interview which uses tablet to screen experience of violence among women in their routine visits. We have collected data from 45 women upon consent.

Evaluation Phase:

• Post PIM Questionnaires collected 6 months post intervention and analysis is ongoing, 12 months Post PIM questionnaires to be collected in December.
• We have done interviews with women (who reported violence and who did not report violence) post-intervention
• We have also collected MSC stories from the health care providers and FCHVs and Women’s Groups)

Publication:

• We are in the process of writing Paper 1 and 2 of the total three planned.
• Paper 1: the turning point of women and help-seeking among women in Nepal who have experienced violence
• Paper 2: Perceptions and readiness among female community volunteers to support women who have experienced domestic violence
• Paper 3: How can health care respond to women who have experienced violence in Nepal?