The Group was co-led by the University of Bristol and London School of Hygiene & Tropical Medicine. Specific country studies were led by the University of Sao Paulo (Brazil), Kathmandu University (Nepal), An-Najah National University (occupied Palestinian territories), and University of Peradeniya (Sri Lanka).

Domestic violence and abuse (DVA) against women is a significant concern in each of these countries, with a prevalence of 23 per cent in Brazil, 27 per cent in Nepal, 29 per cent in the occupied Palestinian territories (oPt), and 24 per cent in Sri Lanka.

Following implementation of the HERA programme, rates of identification of DVA in participating health services increased by 78 per cent in Brazil, 100 per cent in Nepal and 69 per cent in Sri Lanka. There was a 24 per cent decrease in identification of women experiencing DVA in the oPt, partly due to escalating violence in the Israeli occupation*. 

Healthcare worker confidence and motivation to address domestic violence improved, with healthcare workers reporting increases in their readiness to identify, inquire about and respond to domestic violence by documenting cases, making referrals, and offering ongoing support. In Nepal, there was a slight decrease in healthcare worker confidence to offer ongoing support due to the healthcare clinics becoming Covid isolation wards.

Context matters

HERA aimed to strengthen each country’s health system response to DVA by focusing on women-centred care, context-specific adaptations, and healthcare leadership to drive change. It was informed by World Health Organization clinical guidance. The study took place in health services serving socioeconomically disadvantaged communities, focusing on sexual and reproductive health care. This included primary healthcare facilities in Brazil, Nepal, and the oPt, as well as in district general hospitals in Sri Lanka.

Key elements of the intervention were:

• training, which focused on: enhancing understanding of women's experiences, building skills for empathy, asking questions in a non-judgmental manner, and providing first-line support
• improving recording practices
• establishing care pathways for affected women within and beyond the health system.

The adaptation and implementation of HERA in the four countries was shaped by their distinct socio-cultural, political and economic contexts. This included issues such as: drug cartel activities in Brazil and social violence relating to the Israeli occupation of the West Bank*; gender norms and variations in laws regarding violence against women; and challenges posed by the COVID-19 pandemic.

Impact

Training has been vital to address domestic violence in the four countries.

• In Brazil, the south region hopes to expand HERA training to all services in that region, including health services other than primary healthcare (mental health and emergency services, specially).
• The Palestinian Ministry of Health will invite healthcare providers who participated in the "Train the Trainer" programme to train their colleagues in future gender-based violence training sessions.
• The training material developed and used for the HERA intervention in Sri Lanka - to increase awareness and response to DVA among healthcare professionals (HCPs) - has been discussed with the Family Health Bureau (FHB) of the Ministry of Health.  It is hoped the material will be used in their HCP training programme in 2025.
• The HERA team in Nepal was instrumental in advocating for a Gender Transformative Approach (GTA) to train healthcare providers along with the United Nations Population Fund (UNFPA). Currently, the governmental training manual on healthcare response to GBV is being revised to incorporate GTA. The HERA team will train providers/medical students/nursing students/physiotherapy students from different departments and institutions to use the GTA approach.  

Recommendations

The report makes a number of policy and practice recommendations, which include:

• Strengthen health system linkages with local leaders, women’s organisations and non-governmental organisation (NGO)-led services
• Incorporate a robust women-centred perspective in training programmes, grounded in an understanding of gender inequality
• Develop targeted interventions for managers to drive organisational change
• Expand referral options for women at various stages of readiness to seek help
• Maintain a simple, unified record system for documenting DVA
• Establish targets and performance indicators for DVA responses in healthcare systems.

Gene Feder, Professor of Primary Care in the Centre for Academic Primary Care at the University of Bristol and co-Director of HERA, said: “Violence against women is a severe violation of human rights rooted in gender and economic inequalities, affecting nearly one in three women globally. The rates are even higher in some low- and middle-income countries. Health systems play a crucial role in addressing the immediate health needs of women and supporting their pathways to safety and recovery. In HERA we found that health systems in diverse countries in the global South could be strengthened to identify and respond to the needs of women experiencing domestic violence.”

Loraine Bacchus, Professor of Global Public Health at the London School of Hygiene and Tropical Medicine and co-Director of HERA, explained: “HERA has shown that culturally appropriate, women-centred programmes can strengthen healthcare system responses to domestic violence. By collaborating with local health services and addressing the specific challenges faced by their local communities, it is possible to improve healthcare worker confidence and build trust with the women they support. This work highlights the value of country-specific strategies to improve how doctors and other healthcare workers respond to violence against women.”

Professor Ana Flavia d’Oliveira, Principal Investigator, University of São Paulo, said:” Our greatest achievement and the true success of the HERA intervention lie in increasing the identification of domestic violence cases without resorting to mechanical questions or obtaining irrelevant answers. This increase signifies a more attentive and perceptive approach toward women, with a deeper understanding of gender, race, and class inequalities. It also fosters the belief in shared decision-making. 

“Primary care's role in supporting these cases is crucial, serving as an entry point to the rights protection network, despite its limitations. HERA has developed an approach to posing questions, providing support, and making referrals that avoids judgment and re-victimisation. Instead of viewing patients as helpless, it recognises women as empowered individuals capable of making decisions and accepting their consequences.”

Amira Shaheen, Assistant Professor and Principal Investigator, An Najah National University said: "We are deeply committed to advancing healthcare responses to abuse and violence. This initiative not only seeks to strengthen the capacity of our healthcare systems but also to provide a lifeline for those affected. Our work reflects the resilience of communities and the critical role of healthcare in safeguarding human dignity and well-being."

Dr Poonam Rishal, Principal Investigator, Kathmandu University, said: “HERA Nepal has been a collaborative journey to contribute to meaningful work aligning with our passion for fostering change for women who experience violence and abuse. It has been a learning of best practices and challenging existing research that can support policy implementation and amplify voices of women, enriching professional and personal development. Camaraderie, transparency and non-hierarchical leadership were pivotal to its success.”

Professor Thilini Rajapakse, Principal Investigator, University of Peradeniya, said: “Our main aim is to improve the healthcare response to domestic violence, and to increase awareness about this key issue.  We also strongly advocate for improving support and service provision for people experiencing domestic violence, and exploring socio-culturally appropriate ways to do so. HERA has been an important part of our programme.” 

This research was funded by the NIHR (17/63/125) using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the UK Government. The views expressed in this article are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

PolicyBristol report: 
‘Health system interventions can improve domestic violence support but context matters’ by  Loraine J Bacchus, Manuela Colombini (London School of Hygiene & Tropical Medicine), Stephanie Pereira, Ana Flavia d’Oliveira, Lilia Blima Schraiber (University of São Paulo), Poonam Rishal, Kunta Pun (Kathmandu University), Thilini Rajapakse (University of Peradeniya), Amira Shaheen, Abdulsalam Alkaiyat (An-Najah National University), Claudia Garcia Moreno (World Health Organization), Gene Feder (University of Bristol) by PolicyBristol

Papers
 
‘Healthcare professionals' own experiences of domestic violence and abuse: a meta-analysis of prevalence and systematic review of risk markers and consequences’ by Dheensa S, McLindon E, Spencer C et al. in Trauma Violence Abuse 

‘Interventions in sexual and reproductive health services addressing violence against women in low-income and middle-income countries: a mixed-methods systematic review’ by Lewis NV, Munas M, Colombini M, et al. in BMJ Open 

‘Barriers to help-seeking from healthcare professionals amongst women who experience domestic violence - a qualitative study in Sri Lanka’ by Silva, T, Agampodi, T, Evans, M. et al. in BMC Public Health 

‘Engaging early career researchers in a global health research capacity-strengthening programme: a qualitative study‘ by Hawcroft C, Rossi E, Tilouche N et al in Health Research Policy and Systems

‘Evaluation of an intervention to improve Primary Health Care’s response to cases of domestic violence against women - São Paulo, Brazil‘ by Pereira S, Azeredo YN Schraiber, LB et al. in Ciência & Saúde Coletiva 

‘Ethical challenges in global research on health system responses to violence against women: a qualitative study of policy and professional perspectives‘ by Lewis NV, Kalichman B, Azeredo et al. in BMC Medical Ethics

‘Comparing health systems readiness for integrating domestic violence services in Brazil, occupied Palestinian Territories, Nepal and Sri Lanka’ by Colombini M, Shrestha S, Kalichman B et al. in Health Policy and Planning

‘Interventions that prevent or respond to intimate partner violence against women and violence against children: a systematic review‘ by Bacchus LJ, Colombini M, Pearson I et al. in Lancet Public Health

‘Evaluation of a domestic violence training and support intervention in Palestinian primary care clinics: a mixed method study‘ by Joudeh N, Shaheen A, Bacchus LJ et al. in BMC Primary Care.