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Factors Influencing Victims’ Health Seeking to One-Stop Crisis Centers in Bangladesh: Unveiling the Wounds of Violence against Women

Journal of Research in Medical and Dental Science
eISSN No. 2347-2367 pISSN No. 2347-2545

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Review Article - (2023) Volume 11, Issue 1

Factors Influencing Victims’ Health Seeking to One-Stop Crisis Centers in Bangladesh: Unveiling the Wounds of Violence against Women

Shuvashis Saha1, Mohammad Kabir Uddin2*, Shajib Hazari2 and Md Shah Newaz3

*Correspondence: Dr. Mohammad Kabir Uddin, Department of Chemistry, University of Engineering and Technology, Dhaka, Bangladesh, Email:

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Abstract

This study aims to explore the factors that influenced health seeking to the One-Stop Crisis Centers (OCCs) by the victims of Violence Against Women (VAW) in Bangladesh. A qualitative document analysis of 146 case studies of victims from OCCs of different tertiary hospitals along with interviews of care providers working at OCCs were done to understand the help seeking behavior among the victims. Data for document analysis were retrieved from the official news letters published between 2008 to 2018. Four distinct themes emerged which influenced victims health seeking to OCCs: i) situational crisis, ii) social network, iii) legal resources and iv) victims support system. Recognizing the influencing factors of health seeking to OCCs by the victims of VAW might help the policy makers identify the most important gate keepers and channels to OCCs. Greater disclosure and health seeking can be achieved through more lavish community indulgence.

Keywords

Violence against women, One stop crisis centers, Comprehensive care, Health seeking, Sexual violence, Spousal violence, Victims support system

Introduction

Violence Against Women (VAW) is a serious global health problem. According to World Health Organization (WHO), Intimate Partner Violence (IPV) and non-partner sexual abuses are the most common forms of VAW and grave public health concerns. In Bangladesh, more than 50% of married women were found physically and sexually abused by the partners in their lifetime. Current media reports show an alarmingly increased rate of reported non-partner sexual violence incidents. The most commonly committed violence types against women in Bangladesh are domestic violence, acid throwing, rape, child abuse, human trafficking, child labour, and forced prostitution [1].

Health problems do not necessarily cause health seeking. Studies around the world suggest that disclosure and health seeking of abused women are influenced by various socio-demographic factors such as age, education, and income of the victims, type of violence, the severity of violence, having a child, and service accessibility. However, the majority of studies and data regarding the issue are based on the developed countries. Health seeking could be determined by the nature of violence and the availability of different entry points into the health system [2]. Still, there have been very few discussions about which could be the most feasible and important entry point in lower and middle income countries. In Bangladesh, a very low rate of institutional health seeking among battered women, has been found, which is mostly influenced by a difficult, life threatening situation and their children at risk. This study tried to portray an overall picture of formal health seeking by the victims of VAW in Bangladesh with a theoretical approach.

One-stop Crisis Centers (OCCs) are unique structures established within the tertiary level hospitals of Bangladesh providing comprehensive care to VAW victims such as medical care, temporary shelter, psycho-social counselling, legal support, and rehabilitation. From the establishment of the first OCC in 2000 till March 2019, 36441 victims of VAW received care from these OCCs. However, there is little knowledge we know about the victims journey to these shelters. Very few studies have been conducted in these centers because of the restricted access. This study is the first of its kind, taking an indepth insight into factors aiding the health seeking of the survivors at OCCs with the theoretical approach of the socio-ecological model. The socio-ecological model is increasingly being used by researchers and other international organizations like WHO and the Center for Disease Control and prevention (CDC) in order to understand and prevent VAW. The model observes the complex interactions between individuals, relationships, community, and societal factors at different levels to study any interpersonal violence and its traits [3].

Literature Review

Multiple strategies were adopted for data acquisition for this study consisting of document analysis and in-depth interviews of the care providers at OCCs. The data were triangulated for greater validity. Data for qualitative document analysis were acquired from the quarterly published newsletters of Multi-Sectoral Program on Violence Against Women (MSPVAW) containing case studies of the victims of VAW seeking help at OCCs. Thirty newsletters published from 2008 to 2018 were retrieved from the official webpage of MSPVAW16, and 146 case studies from these newsletters were selected for this study narrating the stories of the survivors of VAW seeking help at various OCCs. Case studies were found categorized as physical assault, sexual assault, and burn cases. Document analysis is a systematic review or evaluation of both printed and electronic documents and involves analysis through skimming, reading, and interpretation [4].

Further, a conveniently 5 doctors and 6 nurses were selected for in-depth interviews through personal contacts and snowball technique. The interviews were taken face-to-face or over the telephones. The interviews were audio recorded with prior consent, transcribed and later the audio records were deleted. The six steps thematic analysis of Braun and Clarke was adopted for analyzing the texts from the case studies and the interviews. The theoretical lens of the socio-ecological model guided the emergence of themes through a deductive approach [5]. Emerged themes were discussed, and final themes were reached after further review of data and categorization of earlier themes. Confidentiality was given prime importance while extracting and analyzing data by omitting names and places of residence. Ethical clearance was taken from the ethical review committee of Bangladesh Medical Research Council (BMRC) prior to starting the study.

Discussion

Total 146 case studies of victims of VAW attending various OCCs were analyzed for this study; 69 were physical assault cases, 59 were sexual assault cases, and 18 were burned cases related to VAW. Almost all the physical assault cases were victims of spousal violence, and sexual assault cases were majorly child victims. The majority of victims in the case studies were from rural areas (n=82) and the rest from urban areas (n=58). The backgrounds characteristics of the victims [6].

The qualitative analysis of the case studies resulted in the emergence of 4 themes that influenced the health seeking of the victims to the OCCs. Multiple factors were found aiding the health seeking of the victims to the OCCs ranging from individual to societal dimensions of the socio-ecological model.

Theme 1. Situational crisis

In the majority of cases, health seeking was initiated due to the most recent abusive incident, which caused severe acute injuries and serious deterioration of health. Some incidents were life threatening, and the perpetrators attempted to kill the victims. A generalized delayed health seeking was observed among all violent types of victims [7]. Many rape victims held up disclosing the abusive incidents to the point of late pregnancy. Urgent healthcare needs prompted health seeking to OCCs. A case study narrated the story of a spouse:

A 20-year-old victim was married to a truck driver 4 years back. She was tortured mentally and physically very often for dowry, and it increased day by day. One day husband tied both her hands and feet and pushed broken glass into the vagina, causing severe injury and bleeding. Neighbours informed her father of hearing screaming. She was taken to the local primary health care centre, from where she was referred to Rajshahi medical college and hospital [8]. Two surgeries were performed, and then she was shifted to the OCC of the respective hospital.

Physical assault victims were beaten mercilessly with sticks, iron rods, and bricks, causing abrasion, fracture, swelling, and bleeding in multiple body parts. Few victims were stabbed with knives and strangled by a rope. Some victims reached the OCCs in a senseless condition, and emergency surgeries were required to save their lives. Similarly, many sexual assault victims who were minor girls presented serious health conditions at OCCs like loss of consciousness and severe vaginal bleeding. The story of a 15-year-old sexual abuse victim was narrated by a case study.

A 15-year-old victim studying in class 9 was abducted by a gang of local goons with the help of her friend. She was captivated for 4 days, raped several times and then thrown beside the rail line. She returned home and narrated the whole incident to her mother. Her mother told her to keep it secret for social prestige [9]. However, after 17 days, mental and physical conditions deteriorated severely, so that she was taken to the secondary level hospital of the city. From the hospital, she was referred to OCC of Dhaka medical college and hospital. All forensic and other tests were done, a case was filed and the accused were arrested. She was given treatment as per the advice of the psychiatric department of the respective hospital. Later a medical board was formed as her condition was not changing and treatment given as per the decision of the medical board. She was released after 23 days [10].

Theme 2. Social network

Community people played crucial roles in the journey to OCCs by the victims. In the majority of cases, victims were taken to the hospitals by their parents (n=92) and neighbours (n=26). Fifty case studies depicted, neighbours rescued the victims from the violent scene upon hearing them screaming and took them to a hospital or called their parent. In few cases, local journalists and lawyers assisted victims in getting legal help [11]. The story of a 32 year old housewife depicted in a case study.

The 32-year-old victim got married to an expat 3 years back. After 4 months of marriage, the husband left for abroad. Husband came back later and demanded 5 lac taka for the expenses to take her abroad with him. As her father was dead and her mother could not manage the money. Husband threatened to marry 2nd time for dowry. Some days later she got to know that her husband had married 2nd time. When she protested against the 2nd marriage, she was severely beaten by the husband. On hearing the scream, neighbours rescued her and sent her mother’s house [12]. Later she was taken to OCC of MAG Osmani medical college and hospital.

Theme 3. Legal resources

Law enforcement agencies like the police and its special forces and the local women affairs officers acted as gatekeepers of health seeking. Law enforcers rescued the victims where escape and health seeking were difficult for the victims. One of the case studies narrated the story of a child victim of sexual assault.

A 6 year old was raped by an 18 year old neighbour outside the house. She was threatened not to disclose, but her mother got to know about the matter the next day as she became very sick. However, her mother could not take her to the hospital because of the pressure from local leaders [13]. She took medicines from a local general practitioner. As the news spread, 3 days later, the local women affairs officer came to rescue and took the victim to OCC of Rajshahi medical college and hospital. The accused was arrested. Moreover, legal assistance was provided to the victims in the OCCs to file legal cases against the perpetrators. In 87 case studies, perpetrators were arrested, and 39 were reported absconded [14].

Theme 4. Victim support system

The case studies revealed a network of referral system from various levels of the health system to the OCCs and from OCCs to various departments within the hospital. Twenty-four victims were referred from primary healthcare centres, 10 from secondary level hospitals, and 2 from victim support centres of police [15]. A network of channels helped victims to reach the OCCs, where a comprehensive care model was ensured to them.

OCCs provided healthcare services, medico-legal, and forensic investigation services, legal assistance, social and rehabilitation support, psycho-social counselling, and provision of safe shelter homes. Fifty victims from the case studies received specialized healthcare from various departments of the respective hospitals, and medical boards were formed to provide critical treatment to some seriously ill victims. Within the OCCs various ministries and NGOs were found working together to provide comprehensive care to the victims at OCCs with a multi-sectoral approach. A case study depicted the story of an 11 year girl housemaid.

After an 11 year old housemaid rescued by police from a dustbin in the capital city of Dhaka, she was taken to an OCC and given care for 40 days with the formation of medical boards [16]. While providing legal assistance, the ministry of women affairs requested the ministry of home affairs to shift the case to a speedy trial tribunal. Moreover, OCCs provided temporary safe shelters to the victims. Victims stayed in the OCCs for 2 to 50 days, depending on the need. Social services were managed for some of the victims in the forms of free medicine, free clothes, sewing machine, financial support and shelter home accommodations. A case study on sexual assault narrated the story of a child victim.

A 35 year old sexual abuse victim was a divorcee and jailed for some family dispute. The local mayor helped her to get bail and then took her to his relative’s place, where he raped her [17]. He raped her again at the place and then she went to the OCC. A case was filed. He tried to bribe her, but the victim denied consultation with the OCC personnel. The accused then tried to bribe the coordinator of the OCC and offered 1 lakh taka to remove the evidence of rape. However, the coordinator called the accused with the money and meanwhile informed the elite force RAB. The accused was arrested in the OCC while trying to give money to the coordinator. Cloths and blood samples of the survivor was taken for tests. She stayed in the OCC for 23 days [18].

This study revealed health seeking was triggered by acute health conditions and perceived need for medical care. Support from family and neighbors and assistance from various government legal agencies helped the victims to reach the OCCs. Moreover, the health system referral system allowed the victims channeled to the OCCs. A delayed health seeking was evident in the majority of victims.

Many of the core findings of this study are consistent with various other studies conducted both in developed and developing countries. The delayed health seeking could be explained through the notion of good womanhood in the strict patriarchal South-Asian culture, which attributes silence, tolerance, and virginity to the women. In such a cultural context many women may seek healthcare due to violence, but don’t reveal the actual cause for health seeking [19]. However, OCCs being situated in the urban centers within the tertiary level hospitals and away from the community provide the victims with the privacy and safety they needed in such situation.

This study scrutinized various formal and informal facilitators or gatekeepers of health seeking who played important roles in rescuing and taking the victims to the support centers. Parents and neighbours played dominant roles, which are congruent with other studies conducted in Bangladesh. Formal and legal agencies took dominant roles in more serious cases to rescue the victims. This scenario is different in developed countries where formal sources are the primary resource of disclosure and health seeking of VAW. This difference could be due to the differences in community structures. With proper community awareness, mobilization, and participation programs, community people can be used to achieve greater health seeking among the victims of VAW in Bangladesh [20].

The study further suggested the utilization of the robust health system infrastructure and its referral chain to provide care to the victims of VAW in Bangladesh. A strong primary health care system of Bangladesh previously played a pivotal role in achieving some of the Millennium Development Goals (MDG) [21]. Proper training of healthcare providers might help in greater disclosure and formal health seeking among the victims of VAW in Bangladesh. The study further revealed intersectoral referrals and intra-hospital referrals, which seems to be a very convenient and feasible way to provide comprehensive care to the victims VAW with a one-stop approach in a low resource setting [22].

Considering the agenda and objectives of the MSPVAW, it can be assumed that cases included in the newsletters were intended to show the activities of MSPVAW and OCCs. Generalizability cannot be drawn with such a sample [23]. However, the qualitative inquiry allowed an in-depth insight into the phenomenon of health seeking through the narratives of the victims lives. The findings were primarily descriptive in nature, and no causal relationship could be established.

Conclusion

To conclude, it can be outlined that health seeking to OCCs was initiated due to urgent medical needs and assisted by various formal and informal sources. The case studies revealed that parents and neighbors backed the victims to reach the OCCs in most of the cases. The findings highlight that greater disclosure and formal health seeking of VAW can be achieved through greater community indulgence through community health education programs.

Limitations

We are aware of the limitations associated with this study. Major data used in this study were from secondary source and exact words from the victims couldn’t be accessed resulting considerable chances of reporting bias. Moreover, the care providers mostly reflected their perspective and the actual scenario could not be drawn about the victims help-seeking.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-forprofit sectors.

Conflict of Interest

The authors declared no potential conflict of interest to publication and authorship.

Ethical Approval

Ethical clearance was taken from the ethical review committee of Bangladesh Medical Research Council (BMRC) prior to starting the study.

Acknowledgement

We are very grateful to the personnel at one-stop crisis center in Dhaka medical college hospital for giving us an idea about the source of data.

References

Author Info

Shuvashis Saha1, Mohammad Kabir Uddin2*, Shajib Hazari2 and Md Shah Newaz3

1Department of Electronics and Communication Engineering, University of Engineering and Technology, Khulna, Bangladesh
2Department of Chemistry, University of Engineering and Technology, Dhaka, Bangladesh
3Department of Virolgy, University of Lisbon, Lisbon, Portugal
 

Citation: Shuvashis Saha, Mohammad Kabir Uddin, Shajib Hazari, Md Shah Newaz, Factors Influencing Victims Health Seeking to One-Stop Crisis Centers in Bangladesh: Unveiling the Wounds of Violence against Women, J Res Med Dent Sci, 2023, 11 (01): 256-260.

Received: 09-Sep-2021, Manuscript No. JRMDS-21-41486; , Pre QC No. JRMDS-21-41486(PQ); Editor assigned: 14-Sep-2021, Pre QC No. JRMDS-21-41486(PQ); Reviewed: 28-Sep-2021, QC No. JRMDS-21-41486; Revised: 02-Jan-2023, Manuscript No. JRMDS-21-41486(R); Published: 30-Jan-2023