Bicol University Graduate School Master of Arts in Nursing Legazpi City

ROUTINE DOMESTIC VIOLENCE SCREENING FOR PREGNANT WOMEN IN JOSEFINA BELMONTE DURAN MEMORIAL DISTRICT HOSPITAL

____________________________ A Thesis Presented to the Faculty of the Master of Arts in Nursing Department Bicol University ____________________________

In Partial Fulfillment of the Requirements for the Degree Master of Arts in Nursing ____________________________

Shaira Marise E. Letada, RN

CHAPTER 1 THE PROBLEM AND ITS BACKGROUND

Domestic violence (DV) is a lethal crime, a social peril and a costly public health care problem. Fortinash and Holoday Worret (2004) define domestic violence (DV) as: Learned behaviors used by one or more persons in an intimate or family relationship for the purpose of controlling the behavior of others. Violence may take the form of physical, psychological, sexual, or emotional abuse, intimidation, threats, isolation, economic control, or stalking..1 Unknown to many, it can explode anywhere, any time and within any economic class. DV can take the form of threats, verbal abuse, battering, rape and murder. On a report published by the World Health Organization (WHO), it is clearly stated that half of all women died from homicide killed by their current or former husbands and partners.2 DV is deeply rooted in our culture, sanctioned by religion and codified by common law, wife-battering and corporal punishment were considered a legitimate exercise of a mans power over his wife and his children. Although laws nowadays no longer allow a husband to beat his wife and children, too often DV is still considered a private affair. This attitude has changed somewhat in recent years. However, old attitudes and habits are hard to break and bury. Worldwide, approximately one in every three women will be victimized by DV in their lifetime.3 In the Philippines, while the documentation of all forms of VAW has yet to be achieved, existing data indicate that VAW is still a pervasive social problem. Due to the sensitivity of the issue and its impact on women and their families, many cases of violence often go unreported.

According to some studies, incidence of DV can escalate during pregnancy. This raises a concern for healthcare providers, including nurse practitioners, because it can lead to complications of pregnancy and potentially the death of expectant mothers and their unborn infants. Second only to car accidents, homicide is the most prevalent cause of traumatic death during pregnancy and is responsible for 20% of maternal deaths in the United States.4 In these instances, nurses, doctors and other health care practitioners cater medical services to the victims for health assistance. They are often the first ones who respond to the bloody wounds and painful bruises, often unaware that these were caused by abusive partners unless otherwise reported. On March 27, 2004, the RA 9262 or otherwise known as Anti-Violence Against Women and Their Children, Providing for Protective Measures for Victims, Prescribing Penalties thereof and for other Purposes of 2004 took effect and has legally addressed this issue.5 It has been instituted to criminalize brutal behavior and improve the safety of women. It is a concrete response to a call of the United Nations (UN) in promoting gender equality and peace. This law is also being supported and strengthened by the Philippine Millennium Development Goal (MDG) 5 which aims to promote gender equality and empower women. Despite implementation of these laws against VAW and increased awareness that violence against women is a common occurrence, only a few general health care facilities pay attention to this issue. Regular screening for DV is conducted by less than half of reproductive healthcare providers.6 Little attention is paid to the shortcomings of health care systems that struggle to help victims of domestic violence. Therefore, it is not enough to pass laws that mandate reporting DV and arresting batterers or that make criminal penalties tougher. We should urge building strong, preventive and protective support systems for the victims. Since nurses are at the front lines of the health

profession, they should be trained on how to properly assess and screen women specifically high risk pregnant women for DV during their visit in order to avoid long-term negative effects of violence. Partnerships with different agencies such as the Philippine National Police (PNP) and the Department of Social Welfare and Development (DSWD) that can be partners to resolving such heinous crimes must also be established. Although healthcare practitioners have awareness and understanding of the important roles they play in addressing domestic violence, very few of them live out these responsibilities mainly due to lack of training or experience when it comes to this matter. Added to this is the notion that domestic violence is a private matter and should be kept a family affair. The current study is designed to gather data on the perception of patients and nurses on routine domestic violence screening for pregnant women. During the researchers first year in graduate school, she together with the class in Maternal and Child Health organized the Seminar Workshop entitled, Violence Against Women and Children: Health Practitioners Role. Here, speakers from the Philippine National Police (PNP) and Department of Social Work and Development (DSWD) discussed pertinent information regarding violence against women. Upon listening to these discussions, the researcher realized how limited the nurses roles are in addressing domestic violence especially in pregnant women. Looking back to the researchers experience as a nurse at Josefina Belmonte Duran Memorial District Hospital (JBDMDH), there was not one incident when she or other colleagues questioned about a pregnant womans experience of abuse from her partner since this is not part of the hospitals protocol. This occurrence is what inspired the researcher to venture into this rather sensitive subject matter.

Statement of the Problem This study will look into the implementation of routine domestic violence screening for pregnant women in Josefina Belmonte Duran Memorial District Hospital (JBDMDH). Specifically, it will seek answers to the following inquiries:

1. What is the profile of pregnant patients and nurses in terms of: 1.1 age 1.2 sex 1.3 civil status 1.4 highest educational attainment 1.5 religious affiliation? 2. What are the perceptions of the pregnant patients and nurses towards routine domestic violence screening? 3. Is there any significant difference between the perceptions of the patients and the nurses? 4. What measures may be proposed relative to the implementation of routine domestic violence screening for pregnant women?

Scope and Delimitation This study will be primarily focused on the implementation of routine domestic violence screening for pregnant patients of Josefina Belmonte Duran Memorial District Hospital (JBDMDH). The profile of the respondents who will be pregnant patients and nurses was delimited to age, sex, civil status, highest educational attainment and religious affiliation because they are the ones that have bearing on the perception towards routine domestic

violence screening. All pregnant patients brought to JBDMDH and all nurses employed in the said hospital are respondents of the study. The perception will focus on the respondents overall stance on the implementation of routine domestic violence screening for pregnant patients. Also included in the study will be the determination of the significant difference among the perceptions of the patients and the nurses. In the end, measures relative to the implementation of routine domestic violence screening for pregnant women would become part of the overall output of the study. This study will involve all pregnant women brought to the hospital for a week regardless if admitted or not and all the staff, job order and volunteer nurses working in the hospital. All other factors not mentioned are excluded in the investigation.

Significance of the Study Domestic violence has become a pandemic. This does not exclude the Philippines and in particular the province of Albay. Women today are becoming more aware of their rights. They demand equality and disdain anything that violates their womanhood. With these demands, laws have been passed and implemented regarding the persecution of perpetrators who violate women. However, these laws are not enough. What we need is a system of preventive health care interventions which will screen the victims in order to stop the violence before it gets worse. This study therefore, is intended to benefit the following: Women and their Families The women will be the ultimate beneficiaries of the studys results as this will help them help themselves. Family is the primary support system of the victim and so, this research can aid in educating family members on how to provide support to the target of abuse.

Health Care Workers Being in the front line of the health care team, nurse practitioners are usually the first ones to observe the effects of DV. Therefore, they should be well-equipped with knowledge and training regarding proper approach and documentation of DV. With this research, they will be able to guide the victims and advocate the early detection and prevention of DV.

Government Officials and Organizations (Inter-Agency Council on Violence Against Women and Their Children- IAC-VAWC) Part of a womans support system is the government. Through this research, the government will realize that DV is not just a family affair but, a social problem as well that needs to be immediately and properly addressed. Full and strict implementation of laws concerning VAW must be strictly implemented. This research can be used as a reference material on how to correctly approach and document a DV case.

Law Makers This studys review of the current laws employed against DV can direct policy makers in amending present regulations. They can implement laws which include more specific roles and responsibilities of the health care team when presented with a victim of abuse.

Community Leaders Protection of their constituents from harm and danger is one of the prime obligations of barangay officials. The related literature presented in this research can serve as their guide in promoting safety and in preventing menace in their communities.

Teachers and Academicians This study would underscore the significance of awareness against VAW, DV in particular. In school, awareness can be promoted by educators by incorporating topics against VAW in lectures. Specifically for the nursing course and other allied health care courses, advocacy for anti-violence can be done through organization of seminars and symposia.

General Public The general public is part and parcel of the whole in the prevention, control and solution to DV. Domestic violence is not a private matter anymore. It affects the whole community. For this reason, reporting and calling for help and in behalf of the victim could be possible with their help.

Future Researchers Other researchers who are motivated and dedicated to stopping violence against women can use this research as a reference material in their future endeavors.

Notes
1

Katherine Fortinash et.al. Psychiatric Nursing Care Plans. USA: Mosby, Inc., 1995, p.

667. World Report on Violence and Health: Summary. Geneva, World Health Organization, 2002, p. 15. Valerie Nicole Crawford. Best Practice Screening Women for Domestic Violence in Primary Care Settings, 2007, p. 8, available at http://www.nursing.arizona.edu/Library/Crawford_Valerie.pdf Chang, J., Berg, C., Saltzman, L., & Herndon, J. (2005). Homicide: A leading cause of injury deaths among pregnant and postpartum women in the United States, 19911999. AmericanJournalofPublicHealth, 95(3), 471-477. Republic Act No. 9262 available at http://www.lawphil.net/statutes/repacts/ra2004/ra_9262_2004.html Valerie Nicole Crawford. Best Practice Screening Women for Domestic Violence in Primary Care Settings, 2007, p. 25, available at http://www.nursing.arizona.edu/Library/Crawford_Valerie.pdf
6 5 4 3 2

CHAPTER 2 REVIEW OF RELATED LITERATURE AND STUDIES

This chapter is a presentation and discussion of related literature and studies that have been conducted locally and abroad. These were found to have bearing on the present study that is why they are cited in this chapter in condensed form. It also includes the synthesis of the state-of-the-art, gaps bridged by the study, theoretical and conceptual frameworks, and the definition of terms. Related Literature According to the WHO, Violence is defined as the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, mal-development or deprivation.1 Two of the most common forms of violence against women are abuse by intimate male partners and coerced sex. Intimate partner abuse also known as domestic violence, wifebeating, and battering is almost always accompanied by psychological abuse and in one-quarter to one-half of cases by forced sex as well. The majority of women who are abused by their partners are abused many times. In fact, an atmosphere of terror often permeates abusive relationships. The United Nations Declaration on the Elimination of Violence against Women includes a widely accepted definition of violence against women as any act of gender-based violence that results in, or is likely to result in, physical, sexual, or psychological harm or suffering to

women, including threats of such acts, coercion, or arbitrary deprivations of liberty, whether occurring in public or private life.2 The Declaration defines violence against women as encompassing, but not limited to, three areas: violence occurring in the family, within the general community, and violence perpetrated or condoned by the state. These have bearing to the study since it emphasizes our societys need to be aware of Violence Against Women. It stresses that women be given a voice, a chance to speak up and an opportunity to cry for justice and equality in a society where women face a stigma of being the weaker gender. It also widens the definition of violence against women as not only physical but also psychological and that it is not merely a private affair but a public matter as well. This study will particularly center on violence against women in the family. Violence in the domestic sphere is usually perpetrated by males who are, or who have been, in positions of trust, intimacy and power husbands, boyfriends, fathers, fathers in-law, stepfathers, brothers, uncles, sons, or other relatives.3 Domestic Violence can be manifested through Physical abuse, Sexual abuse, Psychological abuse and Economic abuse. Physical abuse refers to acts that include bodily or physical harm4 such as slapping, beating, arm twisting, stabbing, strangling, burning, choking, kicking, threats with an object or weapon, and murder. Sexual Abuse pertains to an act which is sexual in nature, committed against a woman5 such as coerced sex through threats, intimidation or physical force, forcing unwanted sexual acts or forcing sex with others. Sexual abuse and rape by an intimate partner is not considered a crime in most countries, and women in many societies do not consider forced sex as rape if they are married to, or cohabiting with, the perpetrator.6 The assumption is that once a woman is

married, her husband has the right to unlimited sexual access to her. Some countries have begun to legislate against marital rape including the Philippines. Although provision of such laws represents considerable progress, it is still often difficult for a woman to press charges. Psychological abuse are acts or omissions causing or likely to cause mental or emotional suffering of the victim such as but not limited to intimidation, harassment, stalking, damage to property, public ridicule or humiliation, repeated verbal abuse and mental infidelity.7 It includes behavior that is intended to intimidate and persecute, and takes the form of threats of abandonment or abuse, confinement to the home, surveillance, threats to take away custody of the children, destruction of objects, isolation, verbal aggression and constant humiliation.8 This kind of violence is harder to capture and is less evident than physical battery. Victim- survivors report that ongoing psychological violence emotional torture and living under terror is often more unbearable than the physical brutality, with mental stress leading to a high incidence of suicide and suicide attempts.9 While the impact of physical abuse may be more visible than psychological scarring, repeated humiliation and insults, forced isolation, limitations on social mobility, constant threats of violence and injury, and denial of economic resources are more subtle and insidious forms of violence. Plus, the intangible nature of psychological abuse makes it harder to define and report, leaving the woman in a situation where she is often made to feel mentally destabilized and powerless. It takes place in situations where a woman may seem free to leave, but is held prisoner by fear of further violence against herself and her children, or by lack of resources, family, legal or community support. Economic abuse refers to acts that make or attempt to make a woman financially dependent which includes, but is not limited to the following: 1) withdrawal of financial support or preventing the victim from engaging in any legitimate profession, occupation, business or

activity; 2) deprivation or threat of deprivation of financial resources and the right to the use and enjoyment of the conjugal, community or property owned in common; 3) destroying household property; 4) controlling the victims' own money or properties or solely controlling the conjugal money or properties.10 It also comprises acts such as the denial of funds, refusal to contribute financially, denial of food and basic needs, and controlling access to health care, employment, etc.11 Healthcare should always focus on a persons overall wellness. Therefore, healthcare professionals need to bear in mind that a womans wholeness is damaged by domestic violence and so, efforts should be made to help women pick up every piece of them and put them back together again. Women are more at risk of experiencing violence in intimate relationships than anywhere else.12 According to a UNIFEM report on violence against women, out of 1,327 incidents of violence against women collected between January 2003 and June 2005, 36 women had been killed in 16 cases (44.4 %) by their intimate partners.13 Each year, over 324,000 pregnant women are victims of domestic violence in the United States. A number of countries have sought to statistically analyze the amount of adult women who have experienced domestic violence during pregnancy: 1) UK Prevalence: 3.4% 2) USA Prevalence: 3.4 33.7% 3) Ireland prevalence: 12.5% 4) Canada, Chile, Egypt and Nicaragua: 615%. Incidence rates are higher for teenagers. The incidence rate for low-income, teen mothers is as high as 38%.14 Within the six weeks following birth, 11 new mothers were known to have been murdered by their male partners during 2000-02, and 14% of all the women who died during or immediately after pregnancy (43 women) had reported domestic violence to a health professional during the pregnancy. Between 4 and 9 women in every 100 are abused during

their pregnancies and/or after the birth. Thirty percent (30%) of domestic violence starts in pregnancy and 12% of the 378 women whose death was reported to the Confidential Enquiry on Maternal Deaths had voluntarily reported domestic violence to a healthcare professional during their pregnancy. None had routinely been asked about domestic violence so this is almost certainly an under-estimate.15 This literature goes to show that violence against women can happen to anyone, occur anywhere and at any point in time. It also reveals a high statistics of pregnant victims who do not seek treatment or assistance due to the double standard of society and cultural norms which may lead to maternal death and stillbirth. It also stresses the deficiency and the improper documentation of these cases which then hinders its resolve. Unless this crime is brought to a halt, cases would continue to escalate and long term effects such as denial of fundamental rights, undermining of human development goals and health consequences would persist. International human rights instruments such as the Universal Declaration of Human Rights (UDHR), adopted in 1948 and the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), adopted in 1979, affirm the principles of fundamental rights and freedoms of every human being. The CEDAW is guided by a broad concept of human rights that stretches beyond civil and political rights to the core issues of economic survival, health, and education that affect the quality of daily life for most women.16 The Convention calls for the right to protection from gender-based abuse and neglect. The strength of these treaties rests on an international consensus, and the assumption that all practices that harm women, no matter how deeply they are embedded in culture, must be eradicated. Legally binding under international law for governments that have ratified them, these treaties oblige governments not only to protect women from crimes of violence, but also to investigate violations when they occur and to bring the perpetrators to justice.

Millennium Development Goals are developmental international goals that were agreed upon during the Millennium Summit in 2000. It consists of eight specific and concrete targets that focus on the reduction of the worst forms of human deprivation. There were 193 United Nations member states that committed to achieve it by the year 2015, the Philippines included. We are doing well with some of the goals; however, MDG Five, the Improvement of Maternal Health, is the least likely to be achieved by the target year. The targets under Goal Number 5 are the reduction of maternal mortality rate (MMR) by three quarters by 2015 (half by 2000, half by 2015) and increased access to reproductive health services to 60% by 2005 (80 percent by 2010, and 100 percent by 2015). Maternal Mortality Rate is defined as the number of maternal deaths per 100,000 live births.17 The 1993 and 1998 National Demographic and Health Survey (NDHS) showed that the MMR in the Philippines went down to 172 from the 1993 baseline of 209 deaths. In 2006, the Family Planning Survey (FPS) demonstrated that it declined to 162. Because of MMRs dwindling progression, it is still far from the 2015 target of 52 deaths per 100,000 live births. This slow pace of achieving the target is due to the disturbing reproductive and maternal health situation of women in our country.18 The Department of Health (DOH) has identified the main culprits of maternal deaths, around which they have developed the three delays model. The model consists of the following: (a) delay in deciding to seek medical care; (b) delay in reaching appropriate care; and (c) delay in receiving care at health facilities.19 The discussion of the MDG 5 has a bearing to the study because clandestine cases of domestic violence which are improperly reported and most of the time undocumented especially in pregnant women can and will add up to the burden of the government in hastening the pace towards achieving the MDG 5. We may not know or prove it yet but, domestic violence

may be one of the causes for the three delays model identified by the DOH. Recognition of the fact that as long as womens potentials to participate fully in their society is denied, countries cannot reach their full potential. The Philippine government must therefore commit itself to instigating actions to eliminate violence in all its forms and in all areas of life. In comparison with non-abused women, abused women have a 50-70 per cent increase in gynecological, central nervous system and stress-related problems.20 While physical injury represents only a part of the negative health impacts on women, it is among the more visible forms of violence. The United States Department of Justice has reported that 37 percent of all women who sought medical care in hospital emergency rooms for violence-related injuries were injured by a current or former spouse or partner. Thirty-two (32) assaults result in injuries ranging from bruises and fractures to chronic disabilities such as partial or total loss of hearing or vision, and burns may lead to disfigurement.21 The impact of violence on womens mental health leads to severe and fatal consequences. Battered women have a high incidence of stress and stress-related illnesses such as post-traumatic stress syndrome, panic attacks, depression, sleeping and eating disturbances, elevated blood pressure, alcoholism, drug abuse, and low self-esteem. For some women, fatally depressed and demeaned by their abuser, there seems to be no escape from a violent relationship except suicide.22 Domestic violence is more common than any other health problem among women during pregnancy.23 During pregnancy, domestic violence is categorized as abusive behavior towards a pregnant woman, where the pattern of abuse can often change in terms of severity and frequency of violence. Abuse may be a long-standing problem in a relationship that continues after a woman becomes pregnant or it may commence in pregnancy.24

Experts say that pregnancy is more likely to have an aggravating effect on an abusive partner. One in 6 abused women reports that her partner first abused her during pregnancy and according to the Centers for Disease Control, at least 4 to 8 percent of pregnant women report suffering abuse during pregnancy. Pregnancy can cause stress in any relationship, and it's a common trigger of domestic violence.25 A violent pregnancy is considered high risk because verbal, emotional, and physical abuse all lead to adverse health consequences for both the mother and fetus. Women battered during pregnancy were more frequently and severely beaten throughout the course of their relationship compared to women who were not abused during pregnancy. Intimate Partner Violence also accounts for a large portion of maternal mortality.26 Domestic violences deleterious impact on the maternal and child health is alarming. What is more disturbing is that these effects often go unnoticed. Health care practitioners should pay close attention to these because it has a bearing not only to the mother and childs health but, also to the measures we take as health care professionals in the prevention of maternal and child death. Physical, mental and emotional preparation and stability is a requirement when handling such cases. Clinical eye, vigilance, rationality and fast decisionmaking skills are vital qualities that a health care practitioner must possess when dealing with these situations. These skills can only be put to good and frequent use if protocols for domestic violence screening for pregnant women are created and adopted by health care facilities. It is important that healthcare providers know how properly screen women for domestic violence. Many women have a relationship with a health care provider, particularly during pregnancy, well-baby visits and even after birth. What still needs work is making sure that the care providers and emergency room workers know the signs of abuse and what to do about them. In the U.S., about 17% of all routine health care providers screen for domestic violence at

their first visit, with only 10% screening at subsequent visits.27 Routine enquiry about domestic violence during antenatal booking is infrequent despite such enquiry being included in clinical practice recommendations and is made less frequently than any other aspect of social history taking. Healthcare professionals have a duty to record anything that might impact on the health of their patients including domestic violence. NSF (National Standard Framework) for Children, Young people and Maternity Services includes points on identification of and response to domestic violence in pregnancy. From these, it is mentioned that women should be offered "a supportive environment and the opportunity to disclose" and maternity service staff should be "aware of the importance of domestic violence and competent in recognizing the symptoms and presentations" and "able to make a sensitive enquiry" and "provide basic information" and referral to local services.28 Battered women often seek medical attention for abuse-related injuries as well as health problems that appear unrelated to any specific injury or predisposing health condition. In many cases a physician or nurse may be the only person women feel comfortable talking to about their partners violence. This provides health care providers with a unique opportunity to identify and assist domestic violence survivors.29 Health care professionals need to become involved in the prevention and treatment of domestic violencea public health dilemma. Having a sound knowledge base in this matter is crucial. To intervene in domestic violence requires the HCP to be proactive and to plan interventions. An instant "cure" may not be achieved with the woman in a violent relationship; however, success may be defined as small steps toward empowerment. Screening for domestic violence provides a critical opportunity for disclosure of domestic violence and provides a woman and her health care provider the chance to develop a

plan to protect her safety and improve her health. Recent experience with AIDS, smoking cessation and improved outcomes in breast cancer and cardiovascular disease support the efficacy of early identification and intervention. The prevalence and the health, social and economic costs of domestic violence require equivalent attention and equally effective action by the health care system. A publication produced by The Family Violence Prevention Fund states that the need for a set of clear guidelines for screening practice [of domestic violence] has become apparent. It also presents recommendations for how screening should occur within the healthcare system. The FUND also mentions a general policy statement that all healthcare institutions and practitioners should follow.30 (See Appendix 1) Over the past decade, domestic violence has increasingly been recognized as an important issue for the health system because it has adverse negative impacts on womens physical and psychological health in both the short- and long-term. Abused women use health services at rates higher than other women, with costs to the health system increased when domestic violence is not recognized as the underlying problem. Since most abused women do not present to primary health care settings with injury-related complaints, their history of domestic violence is not commonly identified. While most women do not disclose their

experience of violence to health care providers, they will do so when asked directly about violence and abuse in their lives.31 The debate over routine screening is a debate about how best to improve rates of identification of abused women within health care settings: whether it is better to ask all women routinely, or whether the health care provider should have a high index of suspicion and ask when there are indicators that a woman may have a past or current history of domestic violence. With either approach, the response of the health provider is critical. Survivors report

that a sympathetic and informed response is extremely valuable and can be a catalyst to change. The Philippines has enacted several laws protecting women from violence which includes the Republic Act 9262 also known as, "Anti-Violence Against Women and Their Children Act of 2004". The Act declares that, The State values the dignity of women and children and guarantees full respect for human rights. The State also recognizes the need to protect the family and its members particularly women and children, from violence and threats to their personal safety and security the State shall exert efforts to address violence committed against women and children in keeping with the fundamental freedoms guaranteed under the Constitution and the Provisions of the Universal Declaration of Human Rights, the convention on the Elimination of all forms of discrimination Against Women, Convention on the Rights of the Child and other international human rights instruments of which the Philippines is a party.32 Section 31 of the said act positions that, Any healthcare provider, including, but not limited to, an attending physician, nurse, clinician, barangay health worker, therapist or counselor who suspects abuse or has been informed by the victim of violence shall: (a) properly document any of the victim's physical, emotional or psychological injuries; (b) properly record any of victim's suspicions, observations and circumstances of the examination or visit; (c) automatically provide the victim free of charge a medical certificate concerning the examination or visit; (d) safeguard the records and make them available to the victim upon request at actual cost; and (e) provide the victim immediate and adequate notice of rights and remedies provided under this Act, and services available to them.33 In order for HCPs to perform these duties, Section 42 of the abovementioned act states that training of persons involved in responding to violence against women and their children

cases shall be mandated. 34 They shall be required to undergo education and training to acquaint them with aids they can offer to victims. However, the healthcare team is not alone in this endeavor. Section 39 of this act also established the Inter-Agency Council on Violence Against Women and Their Children (IACVAWC).35 (See Appendix 2) Section 40 is about the Mandatory Services and Programs for Victims. The DOH shall provide medical assistance to victims.36 However, these medical assistance is often just for Medico legal cases which usually focus on physical harm. Treatment, rehabilitation and referral are the typically practiced assistance. Early identification however, is more often than not, missed. The enactment of the RA 9262 and other laws which aim to protect and empower the woman is a concrete step towards the elimination of societal discrimination. Despite its full and strict implementation, amendments to this law should be taken into consideration to specify and improve the healthcare professionals roles.

Related Studies

Local Studies

From a case study by Bernardita D. Patacsil entitled, Violence Against Women: Their Implications to Nursing Practice, she mentioned that (ABSTRACT/RESULTS/SALIENT POINTS).37

Lumen: A Case Study on Domestic Violence by Fleoy Ysmael revealed that a woman victims behavior has a pattern before and after the incidents of abuse. There is a sense of low self-esteem which was later reinforced by the abuses she experienced, defiance at the first instance of abuse which later on turned into helplessness and adaptation to the abuses

acquired. Furthermore, cultural factors contribute to the development of abuse in the family and the reactions of a woman towards an abusive relationship. Moreover, psychological factors, such as the low self-esteem, lack of assertiveness of a woman in a relationship can both be the cause or the effect of the abuse. Finally, abuses can lead to the distortion of the decision-making abilities of a woman victim and the possibilities of seeking for crisis intervention is sometimes vague unless other members of the family have become victims of violence themselves.38

A study by Gil Tuparan entitled, Building a Partnership to Overcome Domestic Violence in the Philippines: The Case of Tessie Fernandez and Bantu Banta talked about the founding of the Lihok-Pilipina Foundation and also briefly discussed the role of Medical Institutions when working with victims of abuse.

The study shared a victims early run-in with the medico-legal section of the Cebu City Medical Center (CCMC), the city government hospital. Apparently, the attending female physician berated the rape victim sent for medico-legal certification thus: "You have been raped already and yet you refuse to spread your legs!" Ms. Fernandez, Lihok-Pilipina founder and Executive Director could only shake her head in disbelief. She calmly went to see the doctor and invited her to attend their NGO's gender sensitivity workshop, which the doctor did. Her frank discussions with Lihok-Pilipina led to a series of training sessions for the medico-legal staff of CCMC, the PNP Crime Laboratory and even private hospitals like the Vicente S. Sotto Medical Center (VSSMC). The sensitization seminars underscored that afflictions could be more than physical, so interventions should be more than medical.

The study later revealed that the CCMC later on established its "Violet Room" and the VSSMC its "Pink Room", to provide the victims of physical and sexual abuse privacy, treatment with sensitivity to their feelings and immediate attention. The hospitals also integrated violence

against women (VAW) with their medical curriculum. Meanwhile, the Silliman University in Dumaguete City made VAW part of its nursing curriculum. Tessie Fernandez joined the panel that critiqued the modules.

Tessie Fernandez also encouraged the Department to look into the women's relationship with their spouses, particularly in cases where the woman sought medical attention but did not show any obvious medical problem. She pointed out that the problem could possibly be due to stress or trauma in the home. Eventually the City Health Department became adept in detecting such cases and referred them to Lihok-Pilipina.39

The local researches mentioned above focused mainly on 1) improving nursing care in all aspects of clinical practice for women victims of violence 2) patterns of behavior before and after incident of abuse and 3) programs that could help healthcare provided and other allied agencies in identifying and referring victims of abuse. Part of this studys objective is to elevate the current nursing practices for domestic violence cases through mandatory screening of pregnant women for domestic violence.

Foreign Studies

Bontha V. Babu and Shantanu K. Kar (2004-2005) of their study on abuse against women in pregnancy in Eastern India, they showed that the prevalence of physical, psychological and sexual domestic violence during a recent pregnancy was found to be 7.1%, 30.6% and 10.4% respectively, and the lifetime prevalence during all pregnancies was 8.3%, 33.4% and 12.6% respectively. Urban living, higher maternal age and husbands alcoholism were the factors associated with domestic violence in pregnancy. Women belonging to lower social groups were less likely to have physical domestic violence. Factors such as higher prevalence of undesirable

behaviors like denying adequate rest and diet, demand for more sex, not providing antenatal care and pressure for male child were also associated with domestic violence in pregnancy. They concluded that Considerable proportions of women experience some type of domestic violence during pregnancy. Health-care providers should be able to recognize and respond to pregnant womens victimization and refer them for appropriate support and care.40 Babu and Kars research has a bearing to the present study because it gives paramount importance to the healthcare providers role in identifying, responding common signs of domestic violence and in referring them to the applicable support persons. Amornrat Sricamsuk (2006) conducted a study on the Thai perspective on domestic violence against pregnant women. The results of the study showed that 53.7% of women reported psychological abuse, 26.6 % experienced threats of and/or acts of physical abuse, and 19.2 % experienced sexual violence during the current pregnancy. In the postpartum period, 35.4% of women reported psychological abuse , 9.5% reported threats of and/or acts of physical abuse, and 11.3% experienced sexual abuse. Women who were abused during pregnancy showed significantly poorer health status compared to non-abused women in role-emotional functioning, vitality, bodily pain, mental health and social functioning. Women who experienced postpartum abuse reported significantly lower mean score in mental health and social functioning than women who did not. Antepartum hemorrhage was found to be statistically associated with physical abuse. No statistical differences were found between abuse status and neonatal outcomes. There were several strategies used by abused women in dealing with domestic violence to maximize their safety including crying, keeping quiet, leaving violent situations and temporarily staying with relatives, seeking help from others, and notifying local authorities. Support services that would be helpful for abused women in dealing with the problem included emotional support, social legal assistance, and community health promotion.

Domestic violence during pregnancy and after birth is an increasing but under-recognized problem in Thailand. It has pervasive consequences on maternal health. The findings from this study suggest more interventions and urgent domestic violence support services need to be established in this remote area of Thailand. This study also suggests routine screening for domestic violence should be established to provide effective early intervention and prevention of adverse consequences of violence, as pregnancy is a time when most pregnant women seek health care.41 The research mentioned above focused on the following: a) effects of abuse to the womans health b) strategies and support services they utilize c) domestic violence is an increasing but rarely documented phenomenon d) screening of women for domestic violence. These are significant to the present study because it encompasses the primary considerations that HCPs must look into when faced with a case of domestic violence such as womens health status, services that they can offer to women and early detection and proper recording. Another related study was conducted by Castro, et al, entitled (RESEARCH TITLE). It aimed to identify the prevalence and types of violence experienced by pregnant women 12 months before and during pregnancy. His respondents were 914 women in their 3rd trimester of pregnancy in 27 prenatal health clinics in the State of Morelos, Mexico. He found out that; 1) 24.4% and 24.5% experienced abuse in the 12 months period before and during pregnancy respectively 2) 12.2% and 10.6% were physically abused before and during pregnancy respectively 3) 18.2% and 20.5% were emotionally abused before and during pregnancy respectively 4) 10.0% and 8.1% were sexually abused before and during pregnancy respectively.42 Sysavanh Phommachanh on a study about Domestic Violence Against Women by Male Partner during Pregnancy in Laos. The researcher found that women had experienced multiple

forms of domestic violence since before pregnancy and during pregnancy. This is due to patriarchal social and cultural structure; because of given gender inequality in terms of the rigid role of male authority as the head of the family, females take submissive roles under the control of the husband. Patriarchal control over [the] female body and sexuality, it is seen pregnant women are much more passive to sex than women without pregnancy. Also, according to the study, although the socio-economic characteristics of informants were not direct factors related to domestic violence, their education and occupation influenced the way they solved problems. Most informants blamed themselves for the violence; this means that they were not able to see the patriarchal social structure as the root cause of domestic violence during pregnancy. Hence, they simply kept silent and tried to conform to patriarchal expectations because the perception in Lao society of domestic violence as a private matter. Other factors associated to domestic violence during pregnancy were unwanted pregnancy, alcohol use, unemployment of husband, jealousy and mother in-law support of the husband.43 The Philippines, like many developing countries still conform to a number of sometimes unjustifiable and discriminating community norms and statures. Domination of men in the family and lack of educational opportunities for women leading to domestic battery and abuse are just some of them. The abovementioned study relates how empowerment is a vital tool in eliminating cultural standards that undermine women. This study therefore, holds a noteworthy position in the present study since its goal is to empower women through effective and efficient nursing interventions in the health care delivery system. These studies attest that domestic violence is not only a threat to the woman but also to her children, her family and the society where she lives in. As such, all of the members of the community especially people working in the field of healthcare must take part in the prevention and control of domestic violence. Much like communicable diseases, DV too, can be eradicated.

In a study conducted by Bonnie M. McClure entitled, Domestic Violence: The Role of the Health Care Professional (HCP) (LOOK FOR IN THE NET), he stated that routine screening of women for domestic violence at initial office visits and annual exams should be encouraged. For some health care professionals (HCPs), asking about domestic violence is synonymous with "opening Pandora's Box" or "opening a can of worms", considering this problem "too complicated" to address. The American Medical Association reported that many professionals are falsely influenced by societal misconceptions including: (a) Domestic violence is a rare occurrence; (b) Domestic violence is a private matter; (c) Domestic violence does not occur in normal relationships; and (d) The woman is somehow responsible for her abuse. Also according to McClure, lack of knowledge and training in domestic violence may contribute to the inability of providers to recognize and correctly interpret behaviors associated with domestic violence. These deficiencies in the education included the inability to identify, assess, document, and manage the care of clients experiencing domestic violence. Also, limitations in the education of obstetrics/gynecology residents related to domestic violence including: (a) lack of faculty interest; (b) underestimated prevalence; and (c) failure to recognize common presentations.44 In an Australian study entitled (TITLE), Bates (2001) explored the factors which enabled women to tell their story. (RESEARCH FOR MORE DETAILS AND RESULTS)45 With Gerbert et al. (1999) in an investigation entitled (TITLE), she found that women identified the attitude of the health care provider to be very important. An attitude which conveyed trust, compassion, support and understanding facilitated women talking about their abuse. Among environmental factors, women mentioned: 1) the size and appearance of the waiting room 2) privacy in the waiting room 3) the triage situation and the consulting area and 4) length of wait for service. Barriers to women discussing their situation included negative

service provider attitudes, lack of continuity of service providers and time constraints on service providers.46 Ease in the evaluation and management of sensitive cases such as domestic violence entails a thoughtful and profound physical, mental and emotional preparedness for healthcare workers. It also necessitates the accommodating and amiable ambiance of the health service unit. These studies have a connection to the present research because they point out the deficiency and scarcity in the education of HCPs in matters concerning domestic violence and the deficiency of health services unit in providing a welcoming environment for its DV clients. These researches also argued how healthcare professionals could have an ultimate chance to gauge and arbitrate in the case of domestic violence if they only knew how to proactively and pre-emptively address this healthcare dilemma. Although concluding that, on the available evidence, it is premature to recommend routine screening programs, the researcher emphasizes that domestic violence is an important issue for the health system, and that health care providers should attempt to identify and support abused women. This is consistent with the recommendations of many medical

organizations for case finding with referral when cases of domestic violence are identified. (RESEARCH FOR ADDITIONAL RELATED STUDIES RELATING DV TO PREGNANCY)

Synthesis of the Art Routine domestic violence screening is certainly a topic of discourse since some might say that this is borderline invasion of privacy. The abovementioned literature and studies discussed about Violence against Women, specifically Domestic Violence. Redefinition of Violence Against Women as an epidemic that is

due to a wide range of interconnected causes which results to physical and psychological harm and injustice to women, their families and the society was established. The efforts of the Philippine government in committing itself to instigating actions to eliminate violence against women through theRepublic Act 9262, was also emphasized. However, a need to improve and to amend this law to indicate a more detailed description of HCPs roles and responsibilities is recommended. Attention was also given to the poor progress of the country in reaching the target for MDG 5 because of incomplete and improper documentation of domestic violence cases especially in pregnant women. Most importantly, the aforementioned literature and studies underscored the health cares noteworthy role in women empowerment and domestic violence prevention and eradication. They cited high statistics of victims who do not seek treatment or assistance due to 1) societys standards, norms and traditions that demoralize women, 2) deficiency in the education and training of HCPs in matters concerning domestic violence and 3) lack of health services unit in providing a welcoming environment for its DV clients. With these, it has also been highlighted that; 1) agencies must work hand in hand to protect and empower women 2) health care practitioners should be physically, mentally and emotionally trained in preventing, questioning, documenting and referring DV cases and that 3) to elevate the current nursing practice in DV cases, routine enquiry and screening should be made available in health agencies. All in all, the literature and studies stress that domestic violence is a reality that should be faced. Women empowerment can be achieved through enhanced nursing assistance which does not merely focus on treatment and rehabilitation but on prevention and early identification.

Gap Bridged by the Study Numerous studies and surveys about violence against women have been conducted to determine its causes and effects to the woman, to her family, to the perpetrator, and to the community as a whole. Almost all of these studies results point out to similar conclusions and recommendations. Nearly all studies done in the past conclude that violence against women is rampant, that it has interrelated origins, and that it has devastating consequences. Most of these studies likewise recommend that measures be taken by the healthcare agencies and other organizations in order to combat domestic violence. With this said no study of similar nature or scope that bear resemblance to the present study has been found. In more specific terms, no study has yet been conducted to determine and compare the perceptions of pregnant patients and nurses towards routine domestic violence screening at Josefina Belmonte Duran Memorial District Hospital. These are gaps that the present study attempted to bridge.

Theoretical Framework According to Hildegard Peplaus Interpersonal Relations Theory, Nursing is an interpersonal process of therapeutic interactions between an individual who is sick or in need of health services and a nurse especially educated to recognize and respond to the need for help. It is a maturing force and an educative instrument.47 Peplau enumerated the Roles of the Nurse: 1) Stranger receives the client. He/she provides an accepting climate that builds trust. 2) Teacher who imparts knowledge in reference to a need or interest. He/she gives instructions and provides training. 3) Resource Person one who provides a specific needed information, answers questions, interprets clinical treatment data and aids in the understanding of a problem or a new situation 4) Counselor helps to

understand and integrate the meaning of current life circumstances, provides guidance and encouragement to make changes 5) Surrogate helps to clarify domains of dependence, interdependence and independence and acts on clients behalf as an advocate. 6) Leader helps client assume maximum responsibility for meeting treatment goals in a mutually satisfying way. She also identified 4 Phases of the Nurse-Patient Relationship: 1) Orientation where an individual or a family has a felt need and seeks professional assistance from a nurse (stranger). This is the problem identification phase. 2) Identification where the patient begins to have feelings of belongingness and a capacity for dealing with the problem, creating an optimistic attitude from which inner strength ensues. Here happens the selection of appropriate professional assistance. 3) Exploitation where the nurse uses communication tools to offer services to the patient, who is expected to take advantage of all services. 4) Resolution where patients needs have already been met by the collaborative efforts between the patient and the nurse. Therapeutic relationship is terminated and the links are dissolved, as patient drifts away from identifying with the nurse as the helping person.48 Nurses are at the front line of health care and are sometimes considered the shock absorbers of the profession. Because of the critical roles that nurses play in assisting pregnant victims of domestic violence, it is imperative that difficulties met during the assistive process be identified and methods to resolve these issues should be instigated. The aforementioned principles serve as the framework of the study.

Theoretical Paradigm

Stranger Teacher Leader

NURSE-PATIENT RELATIONSHIP

Has a felt need. Has a problem.

Has questions.

Orientation

NURSE
Surrogate

Identification Exploitation Resolution

PATIENT

Needs assistance.

Counselor Resource Person In need of health services.

Figure 1. Hildegard Peplaus Interpersonal Relations Theory

Conceptual Framework This study attempted to gather empirical data on the implementation of routine domestic violence screening for pregnant women in hospitals. As depicted in the conceptual paradigm, the profile of the two sets of respondents patients and nurses, included age, sex, civil status, highest educational attainment and religious affiliation. These variables were perceived to affect their perception towards routine domestic violence screening for pregnant women in hospitals. Age refers to the length of time one has existed. Sex is the condition of being male or female. Civil status pertains to (research). Highest educational attainment refers to the highest degree of education an individual has completed and religious affiiation pertains to an organization of religion one is associated with. The perceptions of the patients and nurses focused on the concept of the implementation of routine domestic violence screening in the hospital as part of the routine history taking and assessment. The determination of whether the two sets of respondents agree or disagree with the implementation of routine domestic violence screening in hospitals is based on the questionnaire designed for the purpose. Another component of the research in the verification of the significant difference in the perceptions o the two sets of respondents. The study is also designed to determine if there exists a significant difference in the perceptions of patients and nurses towards the aim of routine domestic violence screening for pregnant women. Finally, the measures which would come from the respondents and researcher herself, will be the ultimate output of the study. Expectedly, they will help in the successful implementation of routine domestic violence screening in hospitals.

Conceptual Paradigm

Profile of pregnant patients and nurses: Age Sex Civil status Highest educational attainment Religious affiliation

Perception of patients and nurses towards routine domestic violence screening for pregnant women in JBDMDH

Significant differences of the perceptions

Patients

Nurses

Suggested measures in the implementation of routine domestic violence screening for pregnant women

Figure 2. Conceptual Paradigm of the Study

Definition of Terms To facilitate better understanding of the research, the following terms have been conceptually and/or operationally defined:

Domestic Violence. Refers to any act of gender-based violence that results in, or is likely to result in, physical, sexual, or psychological harm or suffering to women, including threats of such acts, coercion, or arbitrary deprivations of liberty, whether occurring in public or private life.49 The present study adopts the same definition.

Routine Domestic Violence Screening.

Josefina Belmonte Duran Memorial District Hospital. The locale of the study, is a (short history), located at Tuburan, Ligao City.

Profile. As used in this study, it refers to age, sex, civil status, highest educational attainment and religious affiliation of the respondents of the study.

Perception. Pertains to the conscious recognition and interpretation of sensory stimuli that serve as a basis for understanding, and knowing or for motivating a particular action or reaction.* As used in this study, it refers to the agreeability or disagreeability of the pregnant patients and nurses on the implementation of routine domestic violence screening in hospitals.

Measures. Refers to the steps toward a goal.* In this study, they refer to the recommendations designed to facilitate implementation of hospital-based domestic violence screening for pregnant women.

Notes (REVIEW!!!)

CHAPTER 3 REVIEW OF RELATED LITERATURE AND STUDIES

This chapter presents the entire design and procedures that will be undertaken during the conduct of the study. Specifically, it indicates the research method, research respondents, research instrument and statistical treatment that will be used in the analysis of data.

Research Design This study will be basically a descriptive-comparative type of research because it involves description, recording, analysis and interpretation of condition that now exists.* In more specific terms, the description-comparative survey will be used in this study. The descriptive component involves the description of perception of two sets of respondents while the comparative component covers the determination of significant differences in the perception of the two sets of respondents. A questionnaire which will be formulated by the researcher based on the available literature will be the main instrument in obtaining the needed data.

Sources of Data

There are two sources of data that will be used in this study. The pregnant patients and nurses of JBDMDH, who will serve as respondents, will be the primary sources of data. Internet sources, books, journals, theses and dissertations that have bearing on the study served as secondary sources of data.

Respondents The respondents of the study are the pregnant patients and the nurses of JBDMDH. The patients are those pregnant women who was brought to the Outpatient Department and/or admitted at JBDMDH. The nurses refer to all the nurses employed at JBDMDH either by appointment or voluntarily. The respondents of the study is presented in Table 1.

Table 1 Respondents of the Study Types of Respondents Patients Nurses Number of Respondents -

Research Instrument The survey questionnaires which will be designed by the researcher using the retrieved literature and studies as bases, will be divided into three parts. The first part will be dealing with the profile of the respondents inclusive of age, sex, civil status, highest educational attainment and religious affiliation.

The second part which will be dealing with the perception of patients and nurses regarding routine domestic violence screening will consist of (wala pa ko maisip) will be using the following rating scale: 5 4 3 2 1 ` Strongly Agree (80 100%) Agree (61 80%) Undecided/Uncertain (41 60%) Disagree (21 40%) Strongly Disagree (0 20%)

When quantified relative to the perception of the two groups of respondents, the computed weighted mean will be referred to the following: 4.51 5.00 3.51 4.50 2.51 3.50 1.51 2.50 0.51 1.50 Strongly Agree Agree Undecided/Uncertain Disagree Strongly Disagree

The third part will be the portion where the respondents can suggest measures relative to implementation of routine domestic violence screening in hospitals.

Validation of the Instrument The same instrument will be subject to pre-testing. The researcher will ask permission from the Chief of Hospital of Dr. Sofronio B. Garcia Memorial Hospital to conduct validation process among 10 nurses and patients. Suggestions will be incorporated to facilitate better understanding and easy administration of the instruments among the respondents.

Data Gathering Procedure Permit to conduct the study was secured from the Chief of Hospital of Josefina Belmonte Duran Memorial District Hospital. The copies of the questionnaires will then be distributed and administered personally by the researcher to the respondents. The respondents will be given time to answer the questionnaires during their free time in the presence of the researcher so whatever queries they may have regarding the questionnaire could be answered immediately. The questionnaires will then be collected on the same day they were distributed to prevent a low retrieval rate. Statistical Treatment After all the questionnaires are retrieved, that data will be tabulated, collated and interpreted. The data that will be gathered through the questionnaires will be subjected to simple statistical tools. Frequency count, weighted mean and ranking will be used in the analysis of problems one and two. To determine the significant difference of the two sets of respondents, (stat tx). The formula used for the computation of weighted mean follows:

Where:

X= = N= F =

weighted mean summation total population frequency

Notes