Twenty-four healthcare providers were interviewed to provide their perspectives of survivor experiences during physician-patient interactions (Table 1). Three major themes emerged: (i) perceived survivor needs, (ii) survivor fears/concerns, and (iii) underlying factors (Table 2).
Table 1
Characteristics of healthcare providers in two health facilities, Uganda (N = 28)
Characteristic | Frequency |
Median (IQR) duration of clinical practice, years | 4.0 (0.1–19) |
Gender | |
Male | 7 |
Female | 21 |
Routine IPV screening | |
No | 17 |
Yes | 11 |
IPV training | |
No | 18 |
Yes | 10 |
Clinical specialty | |
Enrolled midwife | 14 |
Registered midwife | 8 |
Medical officer | 4 |
OBGY | 2 |
Providers’ setting | |
Urban | 15 |
Rural | 13 |
Table 2
Code |
Perceived survivor needs |
Need for economic empowerment |
Support for psychosocial needs |
Unaware of GBV service availability |
Survivor fears/concerns |
Persistent safety concerns |
Stigma |
Fear of disclosure of abuse |
Distrust of healthcare providers |
Fear of losing their marriage |
Underlying factors |
Normalizing violence |
Abuse as expression of affection |
Self-blame and shame for abuse |
Unaware of human rights |
Unemployment |
Household poverty |
Perceived Survivor Needs
Need for economic empowerment
Women who experience IPV tend to express feelings of entrapment by their abusive partners because they may not be able to support themselves or their children financially. Financial empowerment efforts enable survivors to become more independent and self-supporting in terms of meeting their own personal and family’s needs. These situations highlight the lack of, and the need for economic empowerment. Our respondents made some suggestions that includes provision of economic empowerment activities through stakeholder collaboration with non-profit organizations as mentioned in the following quotes.
What we feel we can provide is the health part of it, but financially I think we cannot. So, we had an organization [non-profit organization] here dealing with the gender-based violence which is in place. When we receive these mothers and we feel they really need help, we refer them to the gender-based violence department which is based at the ART [anti-retroviral therapy] clinic. [Urban, Female, ANC Midwife 9]
In most cases, when you have discussed with her and you have realized that she does not want the husband to know because when she goes back, she will be in trouble, you need to first handle it but we always involve our leaders, our administration. But for issues we suspect that may go beyond, then we have to involve these other authorities like police … if a woman says I will not go back home, if I go back the man is going to kill me, [then] that is already a threat to her life and the baby who is unborn. So, there is family and child protection unit at police that handle family issues, so they also come in and help. Then, there are also gender based violence offices. They tend to help with that. [Urban, Female, ANC Psychosocial counsellor 16]
Maybe to involve other partners like police, if health workers can work hand in hand with the legal team like police, like the LC1s in the place, we are already having VHTs, police, and the political side has a lot of influence from the community like these counselors (local council chairpersons) [Rural, Female, ANC Midwife 7]
Support For Psychosocial Needs
According to some providers, IPV survivors need psychosocial support to address issues of low self-esteem and helplessness. Respondents expressed optimism about their ability to address psychosocial needs such as self-esteem issues through community awareness raising on GBV. However, one urban-based physician stated that at the healthcare facility level, they lacked the ability to implement this strategy.
I think the community need sensitization and we need empowering of these women. Some may be submissive. That is where the husband says do not and the woman just accepts that, but we have to empower them [women]. One [psycho-social workers] also need to go to the community, to sensitize the community. We may not be able to do it like for us at our level. [Urban, Male, ANC Nurse 2]
Unaware Of Gbv Service Availability
In situations where survivors thought of seeking GBV related support, they often did not know where to get it or where to report abuse experienced. Providers stated that some survivors thought that spousal abuse is not reportable while some survivors were anxious about seeking care from healthcare facilities because of their low levels of trust in the healthcare system.
And the other thing is that they don’t know where to go, at the end of the day, if it is not severe, you know it may not be physical but emotional and she doesn’t know where to go. Most people know that you only go to hospital when you have sickness, so they may not come. They may even fear the hospital more because they know they will just give me drugs, they will not give me anything, so there is that lack of knowledge because they do not know where to go. [Rural, Male, General Medical Doctor 4]
At times they [survivors] even don’t know where to report. They may not even think of it that if there is violence they have to report. Most of them have that knowledge gap. You have to create awareness down to them and when they get to know they will know where to start from. They have that knowledge gap. [Rural, Female, ANC Midwife 5]
Survivor Fears/concerns
Persistent safety concerns
Some healthcare providers, especially those in rural settings, revealed that some IPV survivors usually expressed concerns about continuous threats, including threats of death to themselves or their parents if perpetrators discover that they disclosed abuse to healthcare providers. It is commonplace for survivors to seek help from their immediate or closest family members, especially their parents; however, some respondents revealed that seeking help from family members may not necessarily make it a safe space for survivors as described in the excerpts below.
They fear the husbands. If I talk about it, he is going to do it again. They are in fear all the time. Some have been threatened that “If you go to your parents’ home, I will find you there,” and we have seen women being killed from their parents, you divorce, you go to your parents’ place and then your husband follows you later [to their parent’s home] and kills you from there. [Rural, Male, ANC Nurse 1]
He batters you from his home, you reach time, and you say I cannot hold this anymore, you run to your parents if you are not from far, so they try by all means and get you from there. So you can imagine such a situation. So, they fear so much. If I go to my parents, I will get more problems, even to my parents. It will be now me and my parents. So, when we get those mothers, because there are some who deliver and say I am not going anywhere, because the moment I go back he is going to kill me. [Rural, Female, ANC Midwife 5]
Respondents revealed that they have training needs that would help them provide or make appropriate referrals to stakeholders for supportive GBV care. This is highlighted in the quote below.
You have to train us on how we can screen the mothers and where we can refer these mothers, and what can we do with these mothers. It may not be referring but having the skills that we can handle. So, if you can train us in how we can handle when a mother has such a problem, when gender-based violence is at this rate, you can handle like this and this one we cannot handle. [Rural, Female, ANC Midwife 7]
Stigma
According to one provider, since survivors fear being stigmatized following partner abuse, they confide in a few relatives like their parents. Providers felt that they were the least likely person to whom women will disclose.
When it comes to intimate partner violence, I think there is stigma, and all attached to that. Some people feel offended if you start asking if their partner is violent. So, we leave it to them to bring it forth … Intimate partner violence comes with lots of stigma. When people discuss what has happened to them, they think they will become a laughingstock. So, they prefer not to discuss it. They discuss it with either very close friends or with parents or other relatives but not health workers. What happens in my home stays with me. [Urban, Male, OBGY 6]
Some women don’t want to expose their husbands. Sometimes they fear and say that they respect [their intimate partners]. So, when they talk bad words about their husband, when he is there, she will feel ashamed. [Rural, Female, ANC Midwife 7]
When you are raped here in Uganda, people will want to sit on it because they will feel very embarrassed coming out to say that I am raped. So, same way this person may not easily come out to tell the doctor that this pregnancy was out of rape. [Urban, Male, OBGY 14]
Fear Of Disclosure Of Abuse
Fear of disclosure of abuse
Reasons were mentioned as to why some survivors fear to disclose IPV. According to
our respondents, some survivors of school-going age, usually adolescents, fear disclosing rape, retaliatory partner abuse, and whether the perpetrator partners will get imprisoned. This was highlighted below.
I think they fear to disclose their information … They fear to approach the health
workers, if you don’t ask them, some of them fear to talk, but those ones who can talk
they can tell you. Those ones who fear even if you ask, they keep quiet. [Rural,
Female, ANC Midwife 11]
They always have a feeling that when they bring the husband to you as a health worker for counselling, it is another way of reporting him to the authorities. In the process, the man will be more annoyed, so when they get back home you will be getting some more torture. [Rural, Male, Psychosocial counsellor 15]
Distrust Of Healthcare Providers
Our respondents also cited mistrust of healthcare workers and stigma towards survivors from IPV disclosure, and fear that survivors will receive retaliatory abuse from their partners for disclosing IPV to either healthcare workers, family members or law enforcement (police).
Maybe they are afraid. They have the belief that even if they tell you, you will not provide the solution. Most of them know that even if they tell you [healthcare provider], you know their husband, and that you will go and talk to him. [Urban, Female, ANC Midwife 13]
Some of them they say my husband does not allow me to move and they can say that if I tell you that he beat, he will do such and such a thing to me, or he will chase me away, or he will take me back to my parents, or he will stop even to provide some things to me. [Rural, Female, ANC Midwife 11 ]
They [women attending ANC] always have a feeling that when they bring the husband to you, as a health worker for counseling, is another way of reporting him to the authorities. In the process the man will be more annoyed. So, when they get back home, it will be getting some more torture. So, she will make sure the husband does not come to you. [Rural, Male, Psychosocial counsellor 15]
Fear Of Losing Their Marriage
Respondents stated that some IPV survivors feared that they would end up divorced or separated. Some of these survivor fears were rooted in distrust of healthcare providers disclosing spousal abuse to the survivors’ partners as described in the quotes below.
They fear to lose their marriage … Traditionally, cultural beliefs you are not supposed to report your husband when you quarrel and fight you are supposed to keep quiet until now it becomes beyond but, in most cases, people fear to lose their marriage. [Urban, Female, ANC Psychosocial counsellor 16]
Distrust In Healthcare Providers
Our respondents also described survivors’ lack of trust in the confidentiality of IPV disclosed to healthcare providers. This is mentioned in the quotes below.
I may think mothers are scared that we [healthcare providers] may involve the partners who may deny them custody and then they will not be able to know where to start from. So, they feel they are safe when they have not disclosed. [Urban, Female, ANC Midwife 13]
Since this is an African setting, these mothers at times fail to disclose because of fear of losing the marriage. They know that if I disclose, the ‘musawo’ [doctor] will call my husband, so sometimes they find it hard for them to disclose. [Urban, Female, ANC Midwife 9]
Loss Of Financial Support From Partner
Respondents mentioned that some IPV survivors feared that they would lose support from their partners, especially financial support, if their spouses were arrested or imprisoned after disclosing IPV to the authorities. Such fears lead some GBV survivors to remain silent and not report or disclose abuse to healthcare providers or the police as mentioned below.
Now one of the reasons is that the perpetrators themselves are the main financial supporter to these women. They have a thinking that if they disclose to us, we shall report to police and they [police] will go and arrest them. So, how will she survive? [Urban, Male, General Medical Doctor 10]
Like in this setting, I would say they [survivors] need the support in anyway. So, if they report, they know that I will be on my own. If my man beats me and then I go to report, they [perpetrators] will be imprisoned and then I will be on my own. So, there is that need of their [financial] support during this period. [Rural, Male, General Medical Doctor 4]
Underlying Factors
Normalizing violence
Respondents mentioned that cultural beliefs condoning spousal abuse were held by some survivors. Recommendations to address these beliefs were suggested such as highlighting the need for societal-level sensitization to change such negative attitudes towards women as stated below.
There is need to sensitize the community. They still have that saying that if a man does not beat you, then he does not love you. Some people keep quiet because that is the trend, so they need to sensitize communities. [Rural, Male, General Medical Doctor 4]
Respondents mentioned that some cultural practices, such as dowry, contributes to the perception that women are ‘property’ and ‘owned’ by their male partner who perpetuates IPV.
For this lady, he paid dowry and thinks he owns this person and you become his property. I think to this man he can do anything to the woman which is not fine. [Urban, Female, ANC Midwife 19]
This side, culturally they say a man is right to discipline his wife. For some men, they say that she is my wife and the pregnancy she is carrying is mine. So, I can do anything that I want to do with it. You know they are like this is my wife, and she is my property. Actually, they have a saying that ’namugula’ [I bought her], like you can go and buy your cow and then you say you will kill it. [Rural, Male, ANC Nurse 1]
Abuse as an expression of affection
According to our respondents, some IPV survivors blamed themselves for abuse perpetrated against them by their partners while others were ambivalent about their views towards spousal abuse. For example, one provider mentioned that some survivors viewed abuse towards them as their partners’ way of expressing affection towards them, while other women justified abuse perpetrated against them by stating that partner abuse is culturally acceptable. This is mentioned in the excerpts below.
Some do not talk about it because this is Africa. Someone thinks that if you don’t beat me that means you do not love me. Sometimes women blame themselves that I am the cause of the abuse. That is why women don’t talk about it, they take it as something normal to be abused. [Urban, Female, ANC Midwife 9]
Those cultures teach us that anything that a man does is normal. You are supposed to bear each and every torture because you are a woman, and he is a man. That is why most of the mothers do not talk. For example, if a man forces himself on you, when you are married, most of those mothers do not talk. How will you report when the culture tells us that what took us there is that [being abused]? [Urban, Female, ANC Midwife 13]
Self-blame and shame for abuse
Some respondents mentioned how a few women attending ANC clinics expressed feelings of self-blame or feeling ashamed for abuse perpetrated against them by their intimate partners. Some providers also mentioned that some women justify abuse. These sentiments are highlighted in the quotes below.
Sometimes they blame themselves that I am the cause of the abuse. There is that saying … secrets for the family must remain in the family. They should not be taken to the outsiders. [Rural, Female, ANC Midwife 7]
Some women are really inferior to talk about, they really don’t talk about, I always call them inferiority, they really can’t talk out what happened, there are some mothers who really think if they talk out, they will be ashamed, so you will not know what happened to them. [Rural, Female, ANC Midwife 8]
Those cultures teach us that anything that a man does is normal, you are supposed to through each and every torture because you are a woman, and he is a man and that is why most of the mothers don’t talk. For example, if a man forces himself on you, when you are married, most of those mothers do not talk. How will you report when the culture tells us that what took us there is that.[Urban, Female, ANC Midwife 13]
Unaware of human rights
Providers mentioned that many IPV survivors do not view IPV as a human rights violation, in part because of its normalization in several cultural communities which conflicts with the concepts of human rights. In addition, in some traditions in Uganda view the ‘ideal’ wife as one who does not disclose spousal abuse.
They do not know gender-based violence hurts them. In fact, they don’t know about gender-based violence because according to culture, they teach them to be humble to their men. Even if a man does anything to you, you do not need to report a man to anyone, that is culture. If you go around talking about your husband then that means you are not a woman, in fact not a wife material, you are something else. So, they really cannot talk out because of culture and inferiority that is what really affects them. [Rural, Female, ANC Midwife 8]
Unemployment
According to our respondents, many IPV survivors are not formally employed. Some of the consequences of unemployment that perpetuates IPV include lack of financial independence, reducing women’s decision-making power in the household and hence making women vulnerable to IPV as stated in the quotes below.
Most of the woman around here do not work, they depend on the men. However much she is traumatized by the man because of the life she keeps quiet. [Rural, Male, Psychosocial counsellor 15]
When you look at the mothers who come for antenatal, 90% have no formal jobs. What does this mean? It means that these mothers cannot financially support themselves. In case there is something with this mother which requires money, that means they only depend on their husbands for financial support. [Rural, Male, General Medical Doctor 3]
The women who are not working, the housewives, … stay at home and wait for the man to provide everything. I think they are the ones who are vulnerable people. [Urban, Female, ANC Midwife 17]
Household Poverty
Study participants stated that poverty creates stressful environments which results in conflict in their homes and subsequently into violence. This household violence may arise particularly when men face difficulty or are unable fulfil their role as a provider in the family. The excerpts below describe the effects of household poverty that trigger IPV.
In most cases the root cause to family issues is poverty. So, a woman will say one word because the husband did not buy anything at home and it will spark fire, they will start fighting, but gender-based violence has always been there. [Rural, Male, ANC Nurse 1]
Poverty in the society, because if you screen mothers that are coming [to healthcare facilities], most of them who come in with those GBV cases, they are not financially stable. If you try to talk about it with them, they will tell you that it begun when I asked for money for transport, he is no longer taking care of us you know, … most of the GBVs starts like that and that is why people are getting those GBV cases. [Urban, Female, ANC Midwife 13]