Intimate partner violence in Rwanda

A knowledge, attitudes and practices survey among antenatal care nurses

Master thesis in medicine Lana Bublik

Intimate partner violence in Rwanda

a knowledge, attitudes, and practice survey among antenatal care nurses

Master thesis in Medicine Lana Bublik Supervisors Gunilla Krantz

Department of Community Medicine and Public Health The Sahlgrenska Academy University of Gothenburg

Joseph Ntaganira
Department of Epidemiology and Biostatistics School of Public Health National University of Rwanda

Programme of Medicine, Gothenburg, Sweden 2012

Abstract
Intimate partner violence (IPV) is the most common form of violence against women, with serious consequences for the individual and the society, ranging from functional disorders to suicide and death from injuries sustained. IPV during pregnancy is associated with adverse pregnancy outcomes such as low birth weight and preterm labour, calling for action from antenatal care professionals. More than half of the women in Rwanda have at some point been affected by IPV since the age of 15, and pregnant women are not spared. Health care professionals are likely to meet patients with IPV exposure, but self-reports are sporadic. The World Health Organisation states that routine inquiry can be implemented in the antenatal care setting. Aim: To assess antenatal care nurses knowledge, attitudes and practice towards IPV and readiness to perform routine inquiry. Methods: Structured questionnaires were administered among antenatal care nurses in all health care centres situated in a purposive sample of 7 districts in Rwanda. Out of 116 nurses 64 (a response rate of 55%) a completed the survey. Results: Nurses of North and Central provinces prove ready to accept routine inquiry about IPV, provided that such guidelines are introduced. Present rate of routine inquiry is low (22%) as well as training received (23%), yet knowledge of IPV legislation and health consequences is largely accurate. However one third of the nurses believe that IPV in some situations can be necessary. Conclusions: There is a need for further training on IPV and sensitisation to the issue among antenatal care nurses of the districts surveyed. Whether the results can be generalized to all of Rwandas antenatal care nurses needs further investigation.

List of contents
Abstract ...................................................................................................................................... 3 Introduction ................................................................................................................................ 6 Health consequences .............................................................................................................. 6 Global magnitude ................................................................................................................... 7 IPV in Rwanda ....................................................................................................................... 8 IPV and pregnancy ................................................................................................................. 8 Social acceptance ................................................................................................................... 9 Role of health care professionals ......................................................................................... 10 Barriers to routine inquiry .................................................................................................... 11 Context of the study ............................................................................................................. 12 Aim ........................................................................................................................................... 13 Methods .................................................................................................................................... 13 The questionnaire ................................................................................................................. 15 Data analysis ........................................................................................................................ 15 Interviews ............................................................................................................................. 16 Ethical permissions .............................................................................................................. 16 Results: response frequencies................................................................................................... 17 The survey participants ........................................................................................................ 17 Attitudes towards IPV .......................................................................................................... 19 Practice and experience regarding IPV in clinical setting .................................................... 20 Readiness to accept future guidelines on IPV routine inquiry ............................................. 21 Knowledge about IPV .......................................................................................................... 21 Training on IPV .................................................................................................................... 22 4

Differences in KAP between age groups.............................................................................. 23 Differences in KAP between public and faith based health care centers ............................. 24 Years of experience in antenatal care and differences in KAP............................................. 24 Differences in KAP between male and female nurses ......................................................... 24 Training received and differences in KAP ........................................................................... 25 Discussion ................................................................................................................................ 26 Knowledge about IPV .......................................................................................................... 26 Training received on IPV ..................................................................................................... 27 Attitudes/perceptions about IPV .......................................................................................... 27 Practice/experience with IPV ............................................................................................... 29 Readiness to accept future guidelines on routine inquiry .................................................... 29 Methodological considerations ............................................................................................ 30 Conclusions .............................................................................................................................. 31 Tables........................................................................................................................................ 32 References ................................................................................................................................ 34 Populrvetenskaplig sammanfattning (svenska) ...................................................................... 37 Acknowledgements .................................................................................................................. 38

Introduction
Violence against women is today recognized as a transgression of human rights and a global public health issue. [1-3] Most commonly, the violence occurs within the home, the perpetrators in predominantly being intimate partners/husbands or other relatives of the woman.[4] Intimate partner violence (IPV) can take the form of physical, sexual or emotional abuse or any combination of these.[3] Physical violence encompasses acts such as slapping, kicking and hair pulling, to life-threatening acts, such as burning, strangling or murder. Sexual violence entails forcing a person to have sexual intercourse or perform other sexual acts against his/her will. Emotional abuse includes belittling someone in front of others, threatening or isolating someone. The violence is rarely confined to a single event but rather is a pattern of repeated abuse. Often the different forms of abuse occur together. Pregnant women are not spared. The adverse health effects associated with IPV are substantial, calling for action from health care professionals.[5]

Health consequences Exposure to intimate partner violence is associated with a range of immediate and long-term adverse health outcomes: mortality due to fatal injuries (homicide) or suicide, adverse pregnancy outcomes, mood disorders, suicidal behaviour, gynaecological problems and functional disorders such as irritable bowel syndrome (IBS).[5] Prospective Ugandan research shows that domestic violence puts women at a higher risk of unwanted pregnancy, induced abortion, pregnancy complications such as premature membrane rupture and delivering low birth weight babies.[6, 7] Cross sectional research from Kenya suggests that IPV exposure decreases the likelihood of a woman having skilled attendance at delivery.[8] Increasing skilled attendance at delivery is considered an important tool in fighting maternal mortality in 6

low income countries (Millennium Development goal 5, MDG5). Associations between physical IPV and increased risk of miscarriage, premature labour, depression, delay in seeking antenatal care have been established elsewhere.[9] In summary, the adverse pregnancy outcomes and possible effects on maternal health care seeking make IPV an important risk factor to consider in the strive to decrease child and maternal mortality, and not only a human rights violation in itself.

Global magnitude Intimate partner violence is strikingly common in most settings, early research reporting more than 20 percent women affected in most settings.[10] Lack of uniform definitions and differences in methodology in IPV research have long made it difficult to compare prevalence data across studies and nations.[11] The WHO Multi-country Study on Women's Health and Domestic Violence against Women constructed a cross-culturally valid questionnaire and hereby provides comparable figures by using standardized methodology across 15 sites in 10 countries (mostly low to middle income). Globally, the perpetrator is an intimate partner in 75 percent of cases of physical or sexual abuse that affects women.[4] Worldwide, lifetime prevalence of only physical partner violence ranges from 13 percent in urban Japan to 61 percent in rural Peru. In Tanzania, lifetime prevalence of exposure to physical violence ranges from 33 percent to 47 percent among ever-partnered women.[4] According to a key publication in IPV research, true variations in IPV prevalence on population level (macro level) can be attributed to rigid gender roles, notions of male superiority, acceptance of chastising violence and tolerance of other forms of interpersonal violence in society.[12]

IPV in Rwanda The Rwanda Demographic and Health Survey (DHS) from 2010 reports that 56 percent of ever-married women have experienced violence - either physical or sexual - perpetrated by their husband or partner at some point in their life.[13] In the 12 months preceding the survey, 44 percent had experienced either form of spousal violence.[13] Exposure was assessed using a modified Conflicts Tactics Scale, a commonly used tool in IPV research with questions about specific acts, such as slapping or kicking.[14] Most commonly, women report being kicked, beaten or dragged. Sexual coercion is reported by 17 percent.[13] Lifetime prevalence is somewhat higher among women living in rural setting, 57 percent compared to 46 percent in urban setting.[13] Women with higher income and education level report less violence. Forty-two percent of women sought help to end the violence, most often from friends and neighbours. In the most recent DHS there is no assessment of how many did so from health care professionals, and in the DHS from 2005, only 5 percent reported seeking help from medical personnel.[13, 15] The 2010 IPV prevalence is a dramatic increase since the 2005 survey, where 31 percent of ever-partnered women report exposure to physical or sexual violence from a spouse.[15] This can perhaps be attributed to increased awareness following anti-GBV legislation in 2008 (see Context of the study section) and sensitization campaigns, rendering victims more willing to disclose. A 2010 survey on perceptions of masculinity and GBV conducted by NGO Rwanda Mens Resource Centre, also reports high prevalence more than half of female respondents had experienced IPV, forced sex being the most common (34%) followed by slapping (30%).[16]

IPV and pregnancy Among pregnant women attending antenatal care in Rwanda, 35 percent of the women reported physical abuse (examined by specific acts: being pulled by the hair, slapped, kicked, 8

thrown to the ground, burnt with hot liquid) by a husband/partner during the last 12 months (i.e. a time span including but not limited to the pregnancy).[17] A systematic review of African studies reports physical violence rates among pregnant women between 22,5 percent and 40 percent.[18] Ugandan research reports that 57 percent of women are exposed to domestic violence in the index pregnancy, the perpetrator being an intimate partner in 34 percent of total cases.[19] In a review of Demographic and Health Survey findings from 19 countries, Devries et al report that IPV during pregnancy ranges from 2 % in Denmark, Cambodia and Philippines, to 13,5 % in Uganda.[9] Ideally, according to WHO recommendations for reducing maternal mortality (Millennium Development Goal 5, MDG5), a pregnant woman should attend antenatal care four times before delivery. In Rwandan antenatal care, the partner/husband is present during the first visit for mandatory HIV testing for the couple, but usually not the following three visits.[20] According to the latest Rwandan DHS, 98 percent of women visit antenatal care at least once during pregnancy and 35 percent visit the recommended four times. Late entry into ANC is common.[13]

Social acceptance The latest Rwandan DHS from 2010 included questions about attitudes towards wife beating. It appears that despite legislation and sensitization campaigns, acceptance is still widespread. More women (56 percent) than men (25 percent) accept at least one of the reasons given for wife beating if a woman burns the food, refuses to have sexual intercourse, goes out without telling the husband or neglects the children.[13] Acceptance rates decrease with urban setting, education level and household income.[13] Rates are however lower than in the year 2000 when 47 percent of the Rwandan men and 63 percent of the women stated that IPV is acceptable for any of a series of given reasons (i.e. refusing sex, neglecting children, arguing 9

with husband) maybe suggesting that legislation and campaigns have had positive impact.[21] In a report by Rwanda Mens Resource Centre as many as 70 percent of men and women agree with statements about necessary IPV even after the anti-GBV bill was passed in 2008, and interviews suggest that the change in legislation is not unanimously accepted as positive.[16] No research on IPV attitudes among health care professionals has been conducted in Rwanda before our study, but in neighboring country Tanzania as many as 63 percent female health care professionals state that physical violence is justified for at least one in a series of given reasons (e.g. woman disobeying, refusing sex, being unfaithful).[22, 23] According to Heises ecological framework for factors that interplay in causing IPV, high levels of societal tolerance for correctional violence towards the woman are associated with high prevalence of IPV.[12]

Role of health care professionals As stated above, women exposed to IPV are at risk of many adverse health outcomes and are likely to present to health care providers at some point in their life, with or without obvious signs of violence exposure. This means that health care visits provide an opportunity for disclosure and intervention and that prevention of IPV could reduce ill health, suffering and save health care resources. Many have thus advocated universal screening (the most commonly used term, although the accuracy has been debated, see below) for IPV in medical settings. In 1992, the American Medical Association recommended that all adult women entering primary health care be routinely asked about violence exposure.[24] Many other medical associations in high income countries such as Canada, United Kingdom and Australia have followed.[24] In Sweden, routine inquiry was introduced during a trial period in selected

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antenatal care facilities, following recommendations from the National Board of Health and Welfare (Socialstyrelsen).[25, 26] The WHO states in the World Report on Violence and Health from 2002 that screening, despite lack of systematic evaluation of effects, can be considered good practice in IPV intervention.[1] Since its publication, several reviews of screening outcome studies have been published, concluding that although disclosure rates increase, there is no sound evidence for beneficial outcomes such as decreased abuse of the inquired woman.[24] However, the debate continues as others argue that routinely asking women about violence exposure does not easily fit the criteria of true screening, since the question itself can equal intervention rather than a neutral test, and there is no single treatment or outcome to be measured.[24] In a publication from 2009 on health care responses to violence against women, the WHO concludes on IPV screening In the context of antenatal care, it is possible to make a case for asking at least once based on trial evidence, if it can be done in a safe way without the partner present. It may also be appropriate to screen in the context of pregnancy termination.[27] It is against this background that we conduct our study in antenatal care setting.

Barriers to routine inquiry In contexts where guidelines for routine inquiry exist, inquiry rates still remain low. There is substantial research on health care professionals barriers to screening, commonly reported barriers being: lack of means to intervene once patient discloses, fear of offending the patient, lack of education about IPV and lack of time.[28] A Belgian study among obstetriciangynaecologists suggests that training/education regarding IPV among health care professionals is rare (6,8%), prevalence of IPV is underestimated and routine inquiry is practiced by only 8,4 percent - higher rates of inquiry are reported in case of overt physical 11

signs.[29] Most physicians refute the idea of universal routine inquiry. Lack of time and fear of offending the patient are the most commonly perceived barriers to routine inquiry.[29] A Nigerian study found a 25 percent IPV screening rate among nurses and midwives, and unfortunately many have the negative attitude that the victim is to blame for being abused.[30] Ugandan and Israeli health care professionals report lack of adequate training to identify victims among obstacles in dealing with IPV in a medical setting.[31, 32]

Context of the study Rwanda, a small, landlocked country in Central Africa with 10 million inhabitants is Africa's most densely populated. Rwanda borders to Uganda, Burundi, Tanzania and DR Congo.
Table 1: Basic indicators for Rwanda. Latest available data, from 2008 to 2010, source: Rwanda Ministry of Health[33] and WHO Global Health Observatory Data Repository[34] Population (millions) Adult literacy rate Population living in urban areas Life expectancy at birth Fertility rate (births per woman) Maternal mortality ratio (per 100 000 live births) Infant mortality rate (per 1000 live births) Under 5 mortality rate (per 1,000 live births) Prevalence of HIV (ages 15 to 49) 10,60 70% 19% 55 5,4 540 59 76 to 91 3%

A monarchy that was never affected by slave trade, Rwanda gained independence from Belgian colonial rule in 1962.[35] The political unrest of the 20th century culminated in 1994 with the genocide of close to 1000 000 people.[35] It is estimated that 250,000 to 500,000 women and girls were raped during the genocide, and many were infected with HIV.[16] Today, Rwanda is drawing international attention because of the countrys work for progress and reconciliation. Still struggling with burdens of poverty and communicable diseases, ambitious goals for development have been set - such as becoming a middle income country by year 2020.[36] An affordable health insurance, Mutuelle de Sant, has been introduced, 12

and covers to date 91 percent of the population.[33] Measures have been taken against gender based violence (GBV) and towards gender equality through legislation and establishment of specific government organs. Women became entitled to own and inherit land in 1999 and the bill prohibiting gender based violence and marital rape was passed in 2008. Two important policy documents have been issued, the National Gender Policy and the National Policy against Gender Based Violence. The latter states that the prevention and fight against GBV should[...]be regarded as an integral part of national development as well as the fulfilment of the countrys human rights' obligations.[37] Isange One Stop Centre opened in Kigali in 2009, providing legal, psychosocial and medical services to victims of GBV.[38]

Aim
This study aims to assess knowledge, attitudes and practice (KAP) among antenatal care nurses regarding IPV. We will, if possible despite small sample size, try to examine determinants of differences in the KAP. We stipulate that if the KAP are assessed, future training programs and guidelines can better be adapted to the context. Thereby the role of health care professionals in fighting IPV can be strengthened in Rwanda.

Methods
Type of study: Cross-sectional questionnaire study. Study sample: Nurses working in antenatal care in health centers in Rwanda. Inclusion and data collection: A convenience sample of seven administrative districts in Rwanda based on the availability of Health District Officers able to distribute the questionnaire during 2009. 13

A convenience sample - based on the presence of Health District Officers able to distribute the questionnaire - of seven districts (out of 30) in Rwanda was chosen by Professor Joseph Ntaganira at School of Public Health, National University of Rwanda. In these districts,

Illustration 1: Included health districts in Rwanda with number of survey participants in each district. Adapted from Wikimedia Commons

questionnaires were administered to every health care center with the help of District Health Officers during 2009 (see Illustration 1). Three out of 5 districts in the North province, all 3 districts in the Central province and one district in the South province participated. In each health care facility, questionnaires were administered to two nurses working in antenatal care (the usual arrangement of this service in Rwanda is to have two nurses). The aim was to have full coverage among ANC nurses in each district chosen. Questionnaires were anonymous and participation voluntary. An introductory letter was supplied together with the questionnaires, explaining the background and purpose of the survey. 14

The questionnaire The questionnaire was divided into six sections covering: 1. Nurse demographic information: Q1-Q10 2. Experience and practice with IPV in the clinical setting: Q22-Q25 3. Attitudes towards IPV, which stakeholders should be concerned with IPV: Q11-Q21 4. Readiness to screen for IPV if guidelines are introduced, referral preferences: Q15 and Q25-Q31a 5. Knowledge on IPV prevalence and health consequences: Q32-Q36 and Q39 6. Training on IPV: Q37 and Q38

The original questionnaire was in French and was translated to English for the purpose of this thesis by Professor Joseph Ntaganira.

Data analysis Data was analysed during spring of 2012 by the author of this thesis using SPSS v20. The following adjustments were made to the original data. Choices were originally in 5-step Likert-scale, from strongly agree to strongly disagree. These were merged into agree, uncertain or disagree for the sake of clarity and to increase statistical power when analyzing for determinants. Data on age, length of experience and number of patients seen was merged into groups. Frequency analysis was performed on the responses. Second, using Pearsons Chi Square test, we attempted to assess for differences in key questions between age groups, men and women, urban/rural and public/faith based health center, between those with long/short experience from ANC and between those who had/had not received training on IPV. For variables that were not dichotomized to begin with, such as age, we divided into two groups. In the case of age data, a cut-off point was set between the upper quartile and those 15

younger, and rendered a cut-off point at 35 years of age. For years of experience in antenatal care, this rendered a cut-off at 5 years of experience. For answers in Likert scale, we merged strongly agree with agree, strongly disagree with disagree. For answers in always-to-never scale we merged always with often, and sometimes with never, rendering two groups. Uncertain respondents were omitted from the analysis.

Interviews During the period of data analysis which was conducted in Rwanda during the spring of 2012, several visits were made by the author of this thesis to health centers in Kigali and a hospital in a southern province. During these visits, interviews were held with antenatal care nurses with the intent of gathering better understanding of the context and investigating the possibilities for future qualitative studies. Some of the references in this thesis point to these interviews, and quotes from the interviews are found in the result section.

Ethical permissions Ethical approval for this study was gathered from the School of Public Health and from the Coordinator of Faith Based Health Centers by Professor Joseph Ntaganira who designed the questionnaire, supervised data collection and co-supervised the writing of this thesis.

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Results: response frequencies

Out of an estimate of 116 antenatal care nurses in the seven included districts (estimated two antenatal care nurses per facility multiplied by the number of facilities in each district), 64 completed our questionnaire, rendering a response rate of 55 percent. Number of health care facilities was taken from the Ministry of Health registry.

The survey participants Table 2 displays the characteristics of the survey participants. Out of 64 participants seven were men. Divided into age groups, most were between 20 and 29 years (n=33, 51,6%), mean age was 33 years (SD10,6 years), median age 29. Education level was predominantly (n=57, 89,1%) at A2 level, meaning that the nurse had completed secondary nursing school. University level nursing education (A3) was completed by 4,7 percent (n=3). Nurses without specific training or education were classified as A1 (n=4, 6%). Number of patients in the antenatal care facility each day ranged from 10 to 80, the mean number of patients/day was 28,7 (SD 16,7). Number of patients seen was divided into four groups, most nurses (n=21, 32,8%) were in settings with 10-19 patients each day. Years of experience in antenatal care ranged from 1 to 41, mean length of experience was 6,8 years (SD9,7) with a median at 3 years. Most survey participants (n=40, 62,5%) worked in rural health care facilities as opposed to urban. More health care facilities were public (n=40, 62,5%) as opposed to religious (n=20, 37,5%).

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Table 2: Demographic data on the survey participants (n=64).

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Attitudes towards IPV Table 3 displays the distributions of answers to 10 questions concerning attitudes toward IPV. Most nurses agree that IPV should be a concern for the antenatal care, but not primarily (n=60, 93%). Instead, most believed that IPV should primarily be a concern for specialist care (n=38, 59,4%) or other stakeholders in the community (n=53, 82,8%). The majority of the nurses disagreed with the notion that IPV should be a matter kept inside the family (n=52, 88%). Almost all of the nurses (n=61, 95%) agreed to that they should ask patients about IPV. Participants were asked if personality of women and med respectively, relationship between the woman and the man's family and finally, the man's alcohol consumption were cause of IPV and most participants agreed to the different choices to an equal extent. A key informant explains: I think it's problems in the family... But it's hard to tell the cause, it differs from case to case. Sometimes it's infidelity, sometimes alcohol, sometimes a divorce problem.[39] Other informants attribute IPV to poverty in the family and economical superiority of men over women.[20] One informant believed that in particular sexual violence was connected to drug abuse which she told was widespread in her province.[40] Most disagreed with the statement that women with higher education are more likely to be exposed to IPV. Finally, most (n=40, 62,5%) disagreed with the statement that IPV towards the woman in some situations can be necessary. Still, almost one third agreed (n=18, 28,1%).

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Practice and experience regarding IPV in clinical setting A key informant in an urban, public health centre tells: [We] do not ask every patient about it. This health center receives a lot of patients and time is an issue for us. When these cases present... They only rarely come to us. They are sporadic cases, we refer them on. It is difficult for us to offer such a service.[39]

Table 4 displays frequencies of the answers to four questions about nurses practice and experience with IPV in the clinical setting. Little more than half (n=37, 58%) of the survey participants reported that they had seen a pregnant woman with signs of IPV in their clinic. Out of these 37, the majority (n=23, 62% of responders) reported that they always ask about IPV in such case. There were no participants who reported never asking the question. When seeing a pregnant woman without obvious signs of IPV, one fifth of nurses reported to always ask about IPV (n=14, 21,9%). The majority asked about IPV sporadically (n=27, 42,2%) while 15,6% (n=10) report that they never asked in such cases . The rest asked often (n=13, 20,3%). Most nurses (n=41, 64,1%) believed that patients sporadically tell them about IPV exposure. One fourth (n=16, 25%) of the nurses were of the opinion that women either tell them always or often about exposure to IPV.

A key informant explains: Rwandans do not like to speak of the matters of the home. You have to try and ask in a careful manner, maybe ask the woman if she is happy in her home, when examining her.[20]

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Readiness to accept future guidelines on IPV routine inquiry Table 5 illustrates the answer frequencies to a series of questions on nurses readiness toaccept future routine inquiry guidelines on IPV in their clinical setting, and assesses referral preferences in case of IPV. Nurses (n=57, 89,1%) reported that they would ask all pregnant patients about IPV if guidelines were introduced. The participants further stated (n=49, 76,7%) that they would have enough time to ask pregnant patients about IPV if guidelines were introduced and the workload stayed the same. A general understanding among the nurses was also that today's settings would provide enough privacy for asking pregnant patients about IPV (n=54, 84,4%) in the fututr, and that (n=50, 78,1%) their patients would be comfortable with being asked. Nurses reported in 85,9 percent (n=55) that they would know where to refer a patient exposed to IPV. Among these 55 nurses, police referral was the most common (n=31, 56,4% of 55) choice, either as the only option or in combination with other care givers, such as district hospital or social services. Social service was listed by 38,2 percent (n=21) alone or in combination, followed by district hospital (n=19, 34,5%) accordingly.

Knowledge about IPV Table 6 illustrates response frequencies on questions concerning nurses knowledge about IPV. When asked to rate how common IPV is in the nurses' clinics, most stated that it is uncommon (defined as affecting 1/100 women) or very uncommon (affects 1/1000) (n=45, 70,3%). In contrast, most believed that IPV is common (affects 1/10) or very common (affects 1/3) (n=45, 70,3%) in the Rwandan society in general. Most nurses (n=46, 71,9%) believed that IPV is more common among HIV+ women, that it has negative effects on the woman's health (n=54, 84,4%) and the health of the foetus (n=56, 87,5%).

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Still, 6,3% (n=4) strongly disagreed to that IPV has a negative effect on the woman's health. Most nurses are aware that IPV is forbidden by Rwandan law (n=55, 85,9%).

Training on IPV Around one fourth (n=15, 23,4%) of the survey participants had ever received training regarding IPV all of which expressed the need for more training. According to a key informant, in Bugesera district in south of Rwanda (which was not included in our survey), selected staff at four out of 15 Health Centres had received training on IPV according to personal communication with the district hospital's GBV nurse.[40] The training was provided by EGPAF, a US non-governmental organization. Another key informant (in one of the included districts) stated that training was provided for some staff by Intra-Health, another NGO, that it lasted a couple of days and focused primarily on referral procedures to Isange One Stop Centre.[41]

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Results: differences in KAP

Using Pearsons Chi-Square test in SPSS v20, we assessed differences in distribution of answers according to age, sex, setting, type of health centre and training received. Due to small sample size, multivariate analysis was not conducted - each socio-demographic factor was assessed separately. The questions that were regarded as key questions were: Q21: IPV towards the woman can sometimes be necessary Q15: IPV is a concern to be kept inside the family Q19: Alcohol is to blame for IPV Q23: When I meet a woman with signs of IPV in my clinic, I ask about it Q24: When I meet a woman without signs of IPV, I ask about it

The following section describes the findings by each socio-demographic subgroup.

Differences in KAP between age groups For the purpose of the analysis, participants were divided into two age groups with the cut-off at 35 years. The two age groups were roughly equal in their views on whether it is a family matter. Older nurses were to a greater extent willing to ask women about IPV (60% respond always/often compared to 37% among the younger) even without obvious signs (but p=0,11). All of the nurses above 35 years of age asked women with signs of IPV, compared to 80 percent of the younger nurses (p=0,11). A higher percentage of younger nurses agree that IPV sometimes can be necessary but the difference is not significant. (34% compared to 18% of older nurses, but p=0,3).

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Differences in KAP between public and faith based health care centers There was no difference in rates of inquiry about IPV in absence of signs between public and faith based facilities. In case of IPV signs, more nurses in faith based facilities were reluctant to ask (27 % answered sometimes/never compared to 4,5 % in public health care). The difference was nearly significant (p=0,053). The view that IPV should be kept a family concern was more often supported in faith based facilities, 20 percent agreed compared to 3 percent in public facilities and the difference was significant (p=0,028).Nurses in faith based setting did not justify IPV to a greater extent. There was a significant difference between these two groups in readiness for screening, where nurses in faith based facilities were less willing to accept future guidelines (20 percent compared with 2,5 percent in public facilities, p=0,012)

Years of experience in antenatal care and differences in KAP A cut-off point was set before the uppermost quartile, rendering a cut-off point at 5 years of experience in antenatal care. The upper quartile had an experience more than 5 years, up to 41 years. A nearly significant difference (p=0,057) was found between the two groups with regard to inquiring about IPV in absence of signs, where 62% of nurses with more experience asked always or often whereas only 35% of the less experienced nurses did so. The two groups were roughly equal with regard to IPV acceptance, attribution of alcohol as a cause and perceiving IPV a private family matter.

Differences in KAP between male and female nurses A higher percentage of male nurses disagreed with the notion that IPV should be kept a family matter but the difference was not significant. Men appeared to be more reluctant to inquire about IPV in absence of signs (14 percent compared to 45 percent of women), but this was 24

also not a significant difference (p=0,11). All male nurses (n=7, 100%) disagreed with the notion of necessary IPV, whereas only 65 percent of female nurses disagreed. The difference was close significant (p=0,058).

Urban/rural setting and differences in KAP Nurses in urban setting agreed to a greater extent that IPV sometimes is necessary (56% compared to 14% in rural setting) and the difference was significant (p=0,01). Also, nurses in urban health facilities agreed more often with the notion that IPV is a concern to be kept inside the family (18% compared to 3% in rural setting), and the difference was significant (p=0,046). There was only a slight difference in rates of inquiry in case of overt signs or without signs. We did not find the anticipated difference in views on the role of alcohol, i.e. nurses in rural setting did not agree to a greater extent that alcohol is a cause of IPV.

Training received and differences in KAP The group that had received training had a slightly higher percentage of nurses who always or often asked about IPV even without obvious signs, 53 compared to 38 percent in the nontrained group, but the difference was not significant (p=0,3). In case of obvious signs of IPV, trained nurses did not ask the question more often (83% compared to 87%, p=0,8). Un-trained nurses did not did not show higher rates of IPV acceptance.

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Discussion
Overall, despite the low rate of present routine inquiry about IPV and the perception that it is not primarily a concern for health care, participants proved ready to accept future guidelines on routine inquiry. The training rate was low, yet knowledge of health consequences of IPV, magnitude in society and the accompanying legislation was largely accurately understood by the nurses. Most nurses underestimated the magnitude of the problem in the clinical setting. Taking into account that the survey is conducted in a context where IPV to some extent is accepted and legal measures only recently introduced, it is unfortunate but not surprising that only 62% of nurses disagreed with the notion that IPV can be necessary in some situations. Nurses in urban settings appear to embrace this notion to a greater extent, and also perceive IPV as a private family matter to a greater extent.

Knowledge about IPV Most nurses believed that IPV affects 1 out of 3 pregnant women in the society - in agreement with findings from Ntaganira et al as far as this study in clinical setting can be generalized to the population.[17] The latest DHS contains no figures on IPV prevalence during pregnancy. However, most believed that IPV rarely (expressed as affecting 1/100) affects their patients but as stated in the introduction, Ntaganira et al report a (physical only) IPV prevalence of 35% among ANC patients - indicating that nurses often go unaware of the patients experience. IPV patients far from always present with overt signs of abuse, and if their disclosure rates are low as well as nurses' inquiry rates, it can explain this perception. Still, it is a bit contradictory considering the awareness of high IPV prevalence in general and leaves room for further sensitization to the subject.

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Training received on IPV Only little more than a fifth of nurses had ever received any kind of training on IPV. Low rates of training on IPV are also found in studies on IPV among health care professionals in Belgium, Uganda and Israel. IPV has only in recent years started to gain acceptance as a public health issue, so these rates are expected. In our study, training was not significantly associated with higher rates of asking about IPV, readiness for future routine inquiry or refuting of the idea of IPV as necessary. This could be due to small sample size or because the group who had received training most likely was heterogeneous as to type and length of training.

Attitudes/perceptions about IPV The perception that antenatal care should shoulder responsibility for IPV detection, but not as the main responsible body probably reflects the fact that Rwandan National Police and Ministry of Gender and Family Promotion (MIGEPROF) have been the main stakeholders in anti-GBV campaigns in the country. Isange, the One-Stop Center for IPV victims in Rwandas capital Kigali is adjacent to the Police Hospital and a patient is required a formal referral document from the police before being admitted to the centre's medical care. Despite the attention that gender based violence has been given in Rwanda in recent years, almost one third of our study participants support the notion that IPV towards women in some situations can be necessary. We found a statistically significant difference between urban and rural settings, where nurses in urban setting agreed more often, as well as regarded IPV as a private family matter. Taking into consideration that acceptance of wife beating is assessed more in detail in the DHS2010 than in our study, the figures are still much higher in the general population than among our study participants: 56 percent of women in the general population believe that wife beating is justified for at least one of the specified reasons, compared to 28 27

percent in our sample of antenatal care nurses. It is possible that nurses experience in the clinic with patients affected by IPV could affect nurses into taking a stand against it. In our survey, we did not further explore why IPV by some nurses was considered as necessary in some situations. As far as the difference between urban and rural setting goes, in a study of wife beating acceptance in several Sub Saharan countries, Rani et al report that urban setting is negatively associated with wife beating acceptance in e.g. Uganda and Benin, but no such association was found for Rwanda. Household income was inversely associated with acceptance of IPV. Our result is unexpected also because of the higher rates of acceptance of IPV in rural setting reported in the latest DHS. We were unable to adjust for possible confounding factors such as socio-demographic differences or nurses own experiences of violence. Despite the notion that IPV can be necessary, few nurses agree that IPV is a matter to be kept inside the family (nurses in urban setting agree more often however). In many settings where domestic violence is condoned, a line is drawn between moderate violence which is accepted as a way of correcting the woman for certain transgressions and seen as a private matter, and severe battering resulting in physical injury, where society steps in to prevent. If our survey participants have similar perceptions, this could explain the somewhat contradictory results. Perhaps the nurses find themselves in the middle of a societal change, where government policies and sensitization programs challenge popular beliefs? No single view on what causes IPV stands out as more commonly endorsed. This could have been probed if participants had been asked to rate the different factors rather than only to agree/disagree on each of the statements. Similar perceptions about causes for IPV can be found in a South African study among doctors. We did not assess in the questionnaire, to what extent nurses attributed IPV to such explanations as gender roles, gender equality, economic dependence, etc. 28

Practice/experience with IPV We did not further explore what, in the nurses views, that constitutes signs of IPV but we can assume that it is/entails overt signs of physical violence such as bruises and injuries. One fifth always ask pregnant women about IPV, even without obvious signs of IPV. This rate constitutes the (self-reported) baseline rate of routine inquiry among ANC nurses in the North and Central provinces in Rwanda. If guidelines are introduced it can be compared with future rates. Among Belgian ob-gyn specialists the screening rate is 8,4 percent. Our rate is in level with the rate of 25 percent found among Nigerian nurses. [We] do not ask every patient about it. This health center receives a lot of patients and time is an issue for us. When these cases present, they only rarely come to us. /.../ It is difficult for us to offer such a service. Maybe in the near future we can offer this kind of care, but before that we cannot start inquiring on routine. states one key informant.

Readiness to accept future guidelines on routine inquiry Despite low rates of present routine inquiry, our participants report readiness to ask all pregnant women about IPV, provided that such guidelines were to be introduced. Most feel that today's workload and privacy allow for future routine inquiry and also believe patients would be comfortable with it. This is in contrast with findings among Belgian ob-gyn specialists who report lack of time and fear of offending the patients, and do not agree with the idea of universal routine inquiry. Ugandan health workers on the other hand, believe that screening is difficult yet should be mandatory and that something has to be done to prevent domestic violence urgently. It might be that health care professionals in the Sub-Saharan countries are reacting upon the greater magnitude of IPV in their countries.

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Methodological considerations This is the first study of its kind in Rwanda, and provides an insight into nurses practice, knowledge and attitudes in this important matter. However there are a number of methodological limitations that need acknowledgement. Our survey has a small sample size with a concentration of participants to the North and Central provinces of Rwanda, which were chosen on the basis of District Health Officers available for the distribution of questionnaires. The results can therefore not be generalized to all of Rwanda's antenatal care nurses. The small size of the sample makes it difficult assess differences in knowledge, attitudes and perceptions with certainty. Furthermore, given the complex nature of gender-based violence and the different forms of violence included, we cannot be certain about what particular interpretation our participants employed (not able to assess nurses perceptions of what in their view constitutes IPV), in what situations it is deemed necessary, and whether they draw a line between moderate and severe violence. Also the risk of respondents overestimating or deliberately misreporting their own efficacy in this sensitive matter must be taken into account. The response rate was rather low, resulting in a possible bias towards those who are willing to accept guidelines and who have accurate knowledge being more willing to respond to the questionnaire. However, this small-scale study provides the first insight in this area in Rwanda and the information might be useful for training sessions and follow-up studies. Future studies on the subject would need a larger sample size covering all of Rwandas five provinces and 30 districts, where randomization on the level of health care facilities would be employed. The questions would be designed so as to assess perceptions about specific forms of IPV and how these are dealt with, particularly probing: the notion of necessary IPV, what determines when nurses choose to ask the question or refrain from it, as well as more detailed questions about practice with patients who disclose IPV. Professions other than ANC nurses 30

could also be included, e.g. ob-gyn specialists. The survey could be combined with focus group interviews to gain deeper understanding of the social context and the perceptions that surround the complex problem of intimate partner violence.

Conclusions
This survey provides the first insight into K/A/P of health care professionals in Rwanda regarding intimate partner violence. Antenatal care nurses in North and Central provinces of Rwanda report readiness for routine inquiry if such guidelines are provided. They have largely accurate knowledge about adverse health outcomes and legislation, yet almost one third believe that in some situations violence against women can be necessary. Few have received any training on the matter. Whether the results can be generalized to all of Rwanda's antenatal care nurses needs to be further explored.

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Tables
Table 3: Nurses attitudes towards IPV(n=64)

Table 4: Nurses practice and experience with IPV in the clinical setting

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Table 5: Readiness to accept future routine inquiry guidelines, and referral preferences

Table 6: Knowledge about IPV prevalence and consequences

Table 7: Training received on IPV and perceived need for more training

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Populrvetenskaplig sammanfattning (svenska)

Nr kvinnor drabbas av vld sker det oftast i hemmet och utvaren r en partner eller make. Vldet kan vara fysiskt, sexuellt eller psykiskt. I Rwanda r mer n varannan kvinna drabbad, och gravida r inget undantag. Vldet r inte bara en krnkning av mnskliga rttigheter som de flesta lnder inklusive Rwanda tagit sig att arbeta mot, det har ocks mnga och allvarliga konsekvenser fr hlsan. Gravida kvinnor som utstts fr partnervld lper risk fr allvarliga komplikationer i graviditeten. Drfr r det viktigt att frska frebygga partnervld som ett led i arbetet att minska mdraddligheten, och mdravrdspersonal kan spela en viktig roll hr. I vr studie ville vi underska hur sjukskterskor som arbetar inom mdravrden i Rwanda ser p partnervld, vad de gr nr de trffar patienter som rkat ut fr det, och om de skulle kunna tnka sig att frga sina patienter i strre utstrckning. Det visade sig att de allra flesta har knnedom om att vldet har fljder fr hlsan och kan tnka sig att frga i strre utstrckning om de fr riktlinjer fr det. Dremot tycker en tredjedel att vld mot kvinnan kan vara acceptabelt i vissa situationer, och bara en femtedel brukar rutinmssigt frga patienter om vldsutsatthet.

37

Acknowledgements

My supervisors, Gunilla Krantz and Joseph Ntaganira Staff at Kicukiro Health Center, Kicukiro, Kigali Staff at Nyamata District Hospital, Bugesera district Staff at Isange One-Stop Center, Kacyuru, Kigali Staff at Cor Unum Health Center, Nyarugenge, Kigali Dr Brian Robertson with family Christina Bojesson Ivan & Ljilja Bublik Francine Birundi and Emanuel

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