Gender-based violence: Experiences from two tertiary care settings in Sri Lanka

Background

A retrospective cross-sectional study of pooled data from two GBV care centers attached to two tertiary care hospitals situated in Colombo, Sri Lanka; Castle Street Hospital for Women (CSHW) and Kalubowila General Hospital (KGH), was carried out over a two-year period from January 2017 to December 2019. Both hospitals served an urban population while accepting referrals from other levels hospitals. The CSHW was an exclusive Women’s hospital.

The individual records maintained on all care seekers who had attended these two centers during the study period were perused. There were a total of 495 women (no men) seeking care for GBV from the two centers during the period of study, and all their records were available. There were seven records in which ≥5% of variables had missing values. These records were excluded resulting in 488 being selected for analysis. All the variables were directly reported by care seekers. However, three of the variables (the type of violence, the consequences of violence and reported stable relationships) needed additional interpretation by the health care professionals who entered the data into the records kept in the two GBV care centers. The professionals who worked in the GBV care centers had been trained on data collection and clear instructions had been given to them, regarding data collection and documentation of this data in the records maintained at the GBV care centers.

Data extraction and statistical analysis

From these records, detailed information such as the sociodemographic details, referral modalities, types of violence experienced, the consequences, factors associated with GBV, the characteristics of the perpetrators, health seeking behavior of those seeking care, and the services provided including outward referrals, were extracted by trained research assistants.

In addition, safety assessment of the care seekers was carried out using a safety score as recommended by the World Health Organization (WHO) Hand Book² and highlighted in the Sri Lanka National Guideline for GBV care providers⁸. There were five questions to assess the future safety of those seeking care, with each positive response to a question being allocated a score of one; using the cumulative scores, a risk score was calculated. The following questions were asked:

All the records were retrieved and there was no sampling involved. Therefore, there was no selection bias. Only the records which had significant (≥5%) missing values were excluded. All the research assistants were trained for data collection and they contacted the second author (RP) for any queries and clarifications. Therefore, there was uniformity in data collection, and any bias during interpretation of data was excluded.

The extracted data was entered into data collection sheets (available as Extended data)¹⁰, subsequently entered into an ongoing password-protected database and stored confidentially. Percentages and 95% confidence intervals (CIs) were calculated for the categorical variables. Possible associations of different factors with the types of GBV were assessed using chi square test, odds ratios (OR) and 95% CI. A p-value < 0.05 was considered as significant. Only grouped data are presented, ensuring confidentiality of the care seekers.

Ethical approval

Approval was obtained from the Ethical Review Committee of KGH (PL/MO/2020- application no 843). Participant consent was waived because of the anonymity of the records. Permission to carry out the study was obtained from the directors of the two hospitals KGH and CSHW.

Demographic background of patients

There were 395 (80.9%) from CSHW and 93 (19%) from KGH (p<0.001). Out of 488 women in the study, 358 (73.4%) were married. There were more married women presenting for care at CSHW compared to KGH (275/395 vs 83/93, p<0.001). There were more pregnant women presenting for care at CSHW compared to KGH (170/395 vs 10/93, p<0.001). There were more teenagers presenting for care at CSHW compared to KGH (68/395 vs 4/93, p<0.001). The proportion of women ≥40 years was larger at KGH compared to CSHW (37/93 vs 49/395, p<0.001) (Table 1).

Referrals

A large majority (71%) who attended these two centers had been referred from the wards and outpatient department (OPD). Of the 39 (8%) women referred by the police, 38 had been referred to KGH. The police contributed to 41% of referrals to the KGH and only 0.3% of referrals to CSHW. Other sources or referral, such as general practitioners, other hospitals and lawyers, contributed to 30.4% in KGH compared to 3.0% in CSHW (Table 2).

Experiences of violence

Nearly all (94.3%) had suffered emotional violence. Economic, physical and sexual violence had been experienced by 66.6%, 64.5% and 30.3% of women, respectively, and 180 (37%) of women were pregnant at the time of violence. All four types of violence, i.e. physical, sexual, emotional and economic, were more common in those referred from the wards and OPD compared to other modes of referrals. In total, 10.8% were self-referrals and almost all of them were suffering from emotional violence. Almost all the women who had been referred by the police had experienced physical and emotional violence. All eight women referred from field health staff had emotional and economic violence (Table 3). In cases of self-referral, most women had come to know about the GBV care center through a friend. Posters displayed at these centers also contributed to their knowledge (Table 4). Most women had reported more than one type of violence and 14.5% had reported all four types. Of the 488 women, 69% had experienced both emotional and economic violence while 64% had experienced both physical and emotional violence.

Feeling depressed was the commonest emotional consequence and sleeping disturbances were the next commonest. Suicidal tendencies had been reported by 20%. Lack of interest in sexual relationships was the commonest sexual consequence and bruises and blackouts were the commonest physical consequences (Table 5). In 94% of women, the husband, lover or the living in partner had been the perpetrator. However, there were women who had been subjected to GBV by both husband / lover or the living in partner as well as by other members of the family (Table 6).

Of the 317 women who had suffered physical violence 83% had been married (OR=4.3, 95% CI 2.8-6.6, p<0.001) and 39% had been employed (OR=1.7, 95% CI 1.1-2.6, p=0.009). Of the 148 women who had suffered sexual violence, 49% had been pregnant at the time of violence (OR=2.0, 95% CI 1.4-3.0, p <0.001). Of the 180 pregnant women with GBV, 80% had suffered economic violence (OR=2.6, 95% CI 1.7-4.1, p<0.001). Although 60% of those who had suffered sexual violence were married, marriage and reported stable relationships were associated with reduced risks of sexual violence (OR=0.4, 95% CI 0.3-0.6, p<0.001, and OR=0.5, 95% CI 0.3–0.7, p=0.001, respectively). A reported stable relationship was also associated with a reduced risk of economic violence (OR=0.2, 95% CI 0.2-0.4 p<0.001 (Table 7).

Of the 488 women 90% had spoken to someone about the violence at some point of time. In 55.1% it was either the mother/mother in law or another female family member, and it was a male family member only in 20.9%. While some had confided with a friend, very few women had spoken to a public health midwife, general practitioner or the medical officer in the outpatient department (Table 8). On assessing the future safety of the women who had undergone GBV, the two leading risk factors were that the violence had increased during the previous year (80%), and that the perpetrator consumed alcohol or drugs (60%). Of the 488 women who had undergone GBV 18.6% were afraid to go home (Table 9). Out of a possible total of five, 19% of women had a score of ≥3 indicating a significant risk of repeat violence in the future (Table 10).

Support for survivors

Nearly all women who attended these centers had received emotional support. Of the 488 women with GBV, 182 (37.3%) had been referred to services within the hospital and 64 (13%) had been referred to a psychiatrist. A total of 180 women (36.9%) were referred for services outside the hospital. These included in-depth counselling, and referral to social services, the police and for legal aid. Less than 20% of women were able to bring to the GBV care center a family member and the perpetrator for discussion and counseling respectively. Less than 5% of women voluntarily came for a follow-up visit (Table 11). Only two women came for a second follow-up visit.

Underlying data

These data are available from the Medical Directors of the KGH and CSHW, which are governed by the Ministry of Health, Sri Lanka. Restrictions apply to the availability of these data and are not publicly available. Readers or reviewers who wish to access these data and also those who are interested to use these data for future research can contact Gender and Women’s Health unit, Family Health Bureau (info@fhb.health.gov.lk), Ministry of Health, Sri Lanka.

Research data were stored in a tabular format, in SPSS (Statistical Package for the Social Sciences, Version 25). Numbers 1–93 and 94–488, contained data from the GBV care centers at KGH and CSHW respectively. Each row represents data from an individual woman and each column to represents a variable from the data sheet. There were 141 variables in the data sheet.

Extended data

Figshare: Gender-based violence: Experiences from two tertiary care settings in Sri Lanka. https://doi.org/10.6084/m9.figshare.12084219.v1¹⁰.

This project contains the data extraction sheets used in the present study.

Extended data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).