Violence against women is a human rights violation with grave health consequences and crippling effects on women’s abilities to contribute to societal development. Furthermore, violence against women is a global phenomenon, but women in low-income countries suffer a disproportionate burden. Factors such as economic crisis, political instability and civil unrest amplifies the burden. This is the case in Nepal, where the second phase of the ADVANCE project (Addressing Domestic Violence in Pregnancy 2) is based. 

The ADVANCE project addresses one of the most common types of violence against women, domestic violence, which poses significant health risks to women and their unborn infants in pregnancy. Antenatal care presents an opportunity for women to access adequate assistance that may prevent pregnancy-related complications caused by violence and that can have long-standing effects on maternal and child health.

Antenatal care (ANC) presents a ‘window of opportunity’ to reduce the harmful health consequences of domestic violence as most women use ANC services in their lifetimes (Photo: iStock)

However, to date, evidence of the effectiveness of  interventions to address domestic violence in antenatal care contexts is limited and mainly obtained from studies conducted in high-income countries. Considerable knowledge gaps exist to inform antenatal care providers in identifying and assisting pregnant women living with domestic violence in low-income country settings.

The original phase of the ADVANCE project (Addressing Domestic Violence in Antenatal Care Environments) was funded by the Research Council of Norway from 2013-2018 to fill some of these gaps, in Nepal and Sri Lanka. The ADVANCE project team has now been awarded 11 million Norwegian kroner from the FRIPRO research programme of The Research Council of Norway for a second phase of the project (2020-2025) focused on research activities in Nepal. ADVANCE 2 builds on findings from the first ADVANCE studies, now with the aim of ensuring sustainable and evidence-based changes can be made to antenatal care in Nepal.

How can knowledge from high-income countries be contextually adapted to be relevant and useful in other settings? How can effective low-cost interventions be set in place? How will such interventions reach women in the most remote areas where all types of health services are limited? In contexts where few women living with domestic violence are able to leave the relationship, how can health providers assist in mitigating potential harms to women’s health during pregnancy? These are some of the research questions we will answer in the continuation of the ADVANCE project.

To date, the ADVANCE team has completed a pioneering assessment of the burden of domestic violence in pregnancy in Nepal. We found a substantial proportion (21%) of pregnant women reported the experience of domestic violence, as published in the Scandinavian Journal of Public Health in August 2017. Young age and low socioeconomic status were particular risk factors for experiencing domestic violence. Women who reported having their own income and the autonomy to use it were at significantly lower risk of domestic violence compared to women with no income. The study also found that few women had ever disclosed their experience of domestic violence to a health care provider or been asked about domestic violence by a health provider. This underlines the importance of integrating culturally-sensitive and systematic assessment of domestic violence into antenatal care in the future in Nepal.

Project leaders, Research Fellow Jennifer Infanti and Professor Berit Schei

With ADVANCE 2, our team is planning to improve the assessment instrument we developed for the prevalence study, and formally validate it. The assessment instrument is an adapted version of the Abuse Assessment Screen (AAS), a widely-used five-item instrument originally developed in the USA to detect violence against pregnant women. We have translated the instrument to Nepali language and developed an electronic method of data capture for it called a Colour-Coded Audio Computer-Assisted Self-Interview (C-ACASI). Women wear headphones connected to a tablet computer, listen to the questions read to them by a recorded voice through the headphones, and respond to the answers by pressing colour-coded options (for example, in our study, red = yes and green = no). This technology allows women to answer sensitive questions about domestic violence in privacy in otherwise busy antenatal care settings. Importantly, it also allows for the inclusion of participants with limited or no literacy. In Nepal, the female literacy rate is approximately 67%.

We have also carried out an extensive qualitative study with 41 men and 76 women in 12 focus group discussions in community settings to explore perceptions of domestic violence in pregnancy. This was published in Global Health Action in 2016. In this work, we learned that other events than those covered in the AAS could be classified as domestic violence in Nepal and have the potential for harmful effects on a woman’s pregnancy. The community members identified culturally-specific forms of DV such as mothers-in-law restricting or denying food to pregnant women; being forced to perform long days of heavy manual labour into late pregnancy; bullying, belittling, threats and psychological stress related to dowries; and psychological stress related to cultural preference, familial pressure and taunting to give birth to a son.

Again, ADVANCE 2 builds on this prior knowledge. In the new study, we will modify the AAS to ensure it captures culturally-relevant examples of domestic violence, particularly types of emotional abuse. Our aim is therefore to create the Nepalese Abuse Assessment Screen (N-AAS), which will then be formally validated in our two partner hospitals (Dhulikhel Hospital and Kathmandu Medical College).

Example of illustrations made by a Nepalese artist to explain possible safety measures to practice during pregnancy.

It is critical not only to identify pregnant women living with domestic violence but also to provide them with assistance. In our prior work, we assessed the impact of a safety-promoting intervention delivered on an antenatal care ward at Kathmandu Medical College, in a cohort study. Pregnant women between 12-28 weeks gestation were recruited to the study at their regular antenatal care appointments at the hospital. They were educated about safety measures by a nurse or researcher using a pictorial flipchart that we developed in a teaching session lasting for a maximum of 30 minutes. The flipchart was based on a standardised safety behaviour checklist, originally created in a high-income country setting. We adapted the checklist to ensure the relevance of the safety behaviours for women in Nepal. The figure above is an example of the safety behaviours.

The findings of our study were promising, as published in the International Journal of Environmental Research and Public Health in 2020. We observed that the range of safety measures used by women increased from baseline to follow-up. However, the main weakness was the follow-up cohort study design as we were unable to compare the use of safety measures with other types of intervention. Therefore, in ADVANCE 2, we plan to test the intervention in a randomised controlled trial compared to standard care in both of our partner hospitals. This will expand the evidence-base on health sector interventions to address domestic violence in low-income country settings. The long-term goal is to integrate safety planning into standard antenatal care in Nepal.

The ADVANCE 2 study is led by Research Fellow Jennifer Infanti and Professor Berit Schei (Principal Investigator) at Department of Public Health and Nursing, NTNU. Our former PhD candidates from the original ADVANCE study, now NTNU graduates, will continue in key roles in the project’s second phase. Poonam Rishal is postdoctoral researcher for ADVANCE 2, based at Kathmandu Medical College and Teaching Hospital (KMC). Kunta Devi Pun is co-local Principal Investigator for ADVANCE 2, based at Dhulikhel Hospital-Kathmandu University School of Medical Sciences (KUSMS). Our other local Principal Investigators in Nepal are Sunil Kumar Joshi (KMC) and Rajendra Koju (DH-KUSMS). In Scandinavia, our partner institutions and/or supervisors for the ADVANCE 2 project include Katarina Swahnberg at Linnaeus University (Sweden), Mirjam Lukasse at University of South-Eastern Norway, and Lena Henriksen at Oslo Metropolitan University. Jacquelyn C. Campbell at Johns Hopkins School of Nursing (USA) is international advisor to the project team.

Bloggers: Jennifer J. Infanti (Department of Public Health and General Practice, NTNU), Ragnhild Lund (Department of Geography, NTNU) and Kumudu Wijewardene (Department of Community Medicine, University of Sri Jayawardenepura, Sri Lanka)

Tea plantation near Ella, Sri Lanka (Photo: Jennifer Infanti)

Sri lanka is one of the world’s largest exporters of tea. The origins of the tea plantations date back to the mid-1800s when the country was under British rule.

During this era, the British tea planters brought low-caste, primarily Tamil-speaking labourers from villages in South India to Sri Lanka to work in the plantations. For most of their history in Sri Lanka, the plantation workers were not recognised as citizens of Sri Lanka and therefore had few entitlements or rights in the country. They could not vote, own land, access government health services, open bank accounts, or secure employment outside the tea plantations.

Today, the tea plantation workers have citizenship rights and access to education and free government health care. However, poverty is still widespread in the plantation sector, and social and health inequalities persist.

Tea pluckers at the day’s end, waiting to have their raw tea leaves weighed. (Photo: Jennifer Infanti)

During September and November this year, we carried out six weeks of research in Badulla district – an area in central Sri Lanka known as the ‘hill country’, where approximately 180 tea plantations are located. Our stay was part of the GLOBVAC-funded ADVANCE study, led by Berit Schei, which aims to improve antenatal care provided to women living with domestic violence in Nepal and Sri Lanka.

… aims to improve antenatal care provided to women living with domestic violence in Nepal and Sri Lanka.

Our extended research team in Badulla district. From left to right: Yohan (driver & assistant), Jennifer, Anwara (research assistant), Kumudu, Ragnhild, Jim (driver & assistant).

During our stay in Badulla, we met pregnant women, public health midwives and other health care workers living and working in the tea plantation sector. Our main focus was on how public health midwives identify and care for women living with domestic violence in the plantation sector. What challenges do they face? What resources can they draw from, and where and how are their efforts limited?

To answer these questions, we held a number of group interviews with midwives, covering many of the remote plantations in the district. Following the group interviews, we identified some initial findings and presented these to the midwives at a participatory workshop the following week for their verification and correction.

The prevalence of domestic violence in the plantation sectors, including during pregnancy, is amongst the highest in Sri Lanka. Public health midwives do not have an official mandate to address domestic violence, but in settings where as many as 50 % of women may experience physical violence in their homes, midwives are forced to intervene in some situations due to the potential health consequences of violence for pregnant mothers and their babies.

Workshop with public health midwives. (Photo: Jennifer Infanti).

In our research, we have identified a number of physical, social and symbolic assets and strategies which midwives draw upon or use in order to provide maternal care services to women experiencing domestic violence in the plantation estates. Our findings also point to a wide array of complex institutional and contextual constraints that complicate the provision of care. We are currently analysing our data, and plan to submit our findings to an academic journal in early 2015, so stay tuned for the final results next year.

Photos: Jennifer Infanti & Elisabeth Darj (NTNU), Chandra Yogal (Dhulikhel Hospital-Kathmandu University Hospital)

Elisabeth Darj and I arrived under blue skies at Tribhuvan International Airport on Monday morning, March 24th, 2014. Elisabeth negotiated a price and a verbal guarantee of “safe driving” with a local taxi driver, Rajesh, and we set off with Rajesh on the 30 kilometres drive from the airport to Dhulikhel, the administrative capital of Kavrepalanchok district, Nepal.

Dhulikhel, Kavrepalanchok district, Nepal

Dhulikhel’s population of approximately 14 000 people (2011) is comprised primarily of Newār people who are indigenous to the Kathmandu Valley. The Newārs are traditionally farmers and agriculture continues to be a primary source of livelihood for the majority of people in the community. Our visit coincided with the start of the wheat harvest, and we arrived to landscapes of golden fields and terraced hills.

Elisabeth and I settled into our accommodation at Dhulikhel Lodge Resort and later met our other colleagues from the Department of Public Health and General Practice, Aslak Steinsbekk and Ingunn Harstad, as they returned to the lodge following the first day of Aslak’s week-long course on qualitative research being held at Dhulikhel Hospital.

Dhulikhel Hospital-Kathmandu University Hospital

Dhulikhel Hospital is the teaching hospital of Kathmandu University. It is an independent, not-for-profit institution, serving a population area of approximately 2 million people. NTNU has been formally collaborating with Kathmandu University since 2002 in a variety of disciplines: engineering, natural and social sciences.

In 2007, the Faculty of Medicine (DMF) at NTNU established an official collaboration with the Kathmandu University School of Medical Sciences and Dhulikhel Hospital to facilitate teaching and research exchanges of students and staff between the two institutions. Ingunn Harstad is the current coordinator of this partnership, and the reason we were all in Nepal on this occasion.

With increasing numbers of students from Nepal enrolled in NTNU degree programmes, Ingunn has been encouraging efforts by DMF to offer Master- and PhD-level credit courses locally in Nepal. Aslak agreed to teach his course, Qualitative Research Methods (SMED8015), as the pilot initiative of this project. On this occasion, most of the participants only took part in the week-long course but a few signed up to obtain the full course credits and thus have continued after the week with the required assignments.

Kathmandu University School of Medical Sciences

Elisabeth and I are working on a research study led by Berit Schei, “Evaluating interventions in antenatal care to identify and assist victims of gender-based violence in Nepal and Sri Lanka”. This study employs two NTNU PhD students from Nepal, Poonam Rishal and Kunta Devi Pun, both of whom were enrolled in the qualitative research course.

For the next four days then, Elisabeth and I joined Aslak, Ingunn, Poonam, Kunta and the 15 other students in the course for a series of lectures and group-based project work. Between breaks for masala tea and lunches of dal baht or momos (Nepali dumplings) at the hospital canteen, we learned strategies to collect data using interviews and focus groups and became more familiar with the techniques of thematic qualitative data analysis. Overall, the course participants were enthusiastic and diligent, and the quality of the group conversations and project presentations more than met teaching expectations. Elisabeth and I also had the opportunity to work with our two PhD students in the evenings on their projects, making it a very productive week for all of us.

Course on Qualitative Research Methods

The Faculty of Medicine at NTNU is delighted to welcome four doctors/researchers from Nepal to Trondheim between January 15th and 17th. The visiting delegates are members of an international collaboration of researchers investigating strategies to improve antenatal care for pregnant women experiencing domestic violence in Nepal and Sri Lanka. This research team is led by Professor Berit Schei of The Department of Public Health and General Practice and funded by the Research Council of Norway under its GLOBVAC programme.

Domestic violence is a profound global health problem.

At the Obstetrics & Gynaecology Department at St. Olavs Hospital. From left to right, the people are: Dr. Rajendra Koju, Dr. Sunil Kumar Joshi, Dr. Chanda Karki, Dr. Meena Thapa. (Photo: Jennifer Infanti)

The guests from Nepal include Dr. Chanda Karki, Professor in the Department of Obstetrics and Gynaecology and Principal (Dean) of Kathmandu Medical College and Teaching Hospital (KMC); Dr. Meena Thapa, Associate Professor of Obstretics and Gynaecology at KMC; Dr. Sunil Kumar Joshi, Associate Professor in the Medical Education Department at KMC; and Dr. Rajendra Koju, medical doctor at Dhulikhel Hospital and Associate Dean of the Kathmandu University School of Medical Sciences.

Domestic violence is a profound global health problem, posing significant risks for the physical, sexual and psychological health and well-being of women and children in particular. Domestic violence crosses all geographic, economic and cultural barriers and borders. Despite the significant risks of domestic violence for poor health, rigorously conducted research on the interventions, services and policies that work best to prevent and respond to domestic violence is limited.

The four guests from Nepal are standing or sitting from left to right as follows: Dr. Sunil Kumar Joshi (standing), Dr. Chanda Karki, Dr. Rajendra Koju, Dr. Meena Thapa. (Photo: Jennifer Infanti).

In addition, addressing such a widespread public health challenge requires cooperative actions and solutions which bridge many sectors of society – for example, governments, non-profit organisations, researchers, and health care. Professor Schei’s project strengthens the formal partnership of NTNU and Kathmandu University to advance such a cross-cultural exchange of skills, knowledge and experiences to tackle domestic violence.

The visiting doctors/researchers from Nepal will have the opportunity to meet with some of Trondheim’s service providers for victims of domestic violence during their stay, including the Sexual Assault Care Centre team at St. Olavs Hospital, staff at the Trondheim Crisis Centre, and victim support officers and investigators at the police station. In addition, they will be sharing their experiences in obstetrics and public health in Nepal at various meetings and seminars at St. Olavs hospital and NTNU.

Dr. Chanda Karki is speaking at the podium. (Photo: Jennifer Infanri)

Importantly for the research project, the visit will allow time to further develop two PhD proposals – the funding from the Norwegian Research Council for this project will allow two students from Nepal to complete PhD degrees at NTNU over the next three years. The doctoral projects aim to develop culturally and contextually sensitive screening tools to identify pregnant women experiencing domestic violence in antenatal care settings in the Kathmandu area of Nepal. In addition, the PhD students will each develop training and education interventions to support health care professionals in their work with victims of domestic violence. The goal of the interventions is to improve the safety of pregnant women by either reducing the recurrence of abuse or mitigating its impact and consequences.

Professor Schei’s study aligns with the strategic efforts of the Faculty of Medicine at NTNU and St. Olavs Hospital to build competency in the field of global health. The Faculty will benefit from the skills and knowledge of health care practitioners from other countries. With Norway’s population becoming increasingly multicultural, this will help us prepare for patients coming to the hospitals from diverse cultural and ethnic backgrounds, contributing to a more culturally responsive health care system.

Mr. Børge Brende, the Minister of Foreign Affairs together with May-Britt Moser, Edvard Moser and the Dean at the The Faculty of Medicine, NTNU, Stig Slørdahl.

Mr. Børge Brende, the Minister of Foreign Affairs visited NTNU yesterday. After a meeting with the Rector, the minister gave an inspiring talk to staff and students about geopolitical changes.

He was then presented with the Medical Faculty’s ideas of how to work with global health, and a tour of the Kavli Institute’s lab.

On the first of September I started my work as the first professor in Global Health at NTNU and I have now been asked to present myself. I’m most honored to have this job opportunity and it has been two intense, interesting and exciting months. My office is at Department of Public Health and General Practice.

I am a Swedish obstetrician and gynecologist and have been working clinically for many years. Simultaneously I have always been engaged in education and research. While employed at Uppsala University in Sweden I have taught medical students, midwives, nurses and biomedical assistants among others.

My research profile is in obstetrics and gynecology, but for more than ten years I have focused on reproductive health in low income countries, mainly in East-Africa, where I have supervised PhD and Master’s students. I have conducted research in women’s health from different angles: maternal health and mortality, support in the post-partum period, abortions, violence against women and children, adolescents’ reproductive health, infectious diseases, such as STI/HIV and health systems. I am now involved in a project at NTNU on violence against women in Nepal and Sri Lanka, and have applied for funds for other projects with others.

Mother and child in Tanzania

Global health is defined as health issues that transcend national boundaries and call for research and actions to improve health for all, irrespective of where we live. “Collaborative international research and action for promoting health for all”. As health is influenced by politics, society, culture and the environment, solutions to health problems not only reside within health systems, but also elsewhere. I have already met a lot of people in Trondheim with strong interests in global health who are engaged in different research projects in various faculties. In the medical faculty there are well-established cooperations and projects in Nepal, Sierra Leone, Malawi and South-Africa. I recently lectured to a large group of medical students and almost all of them had been travelling outside Europe. They showed knowledge and great interest in global health and in solutions to challenging issues. So I think it is timely that the medical faculty has now decided that Global Health shall be included in all education.A new two-year international Master’s program in global health will be developed, which is exciting and challenging, and I’m sure it will benefit research and education.

Furthermore, we wish to increase collaboration with other faculties, institutions, HiST and other actors. At the moment, we are updating the global health program that already exists for medical students. Two weeks ago there was the annual Global Health Day, held for the fourth year, and showing a growing interest in the topic with, now almost 200 participants. There were many stimulating presentations during the day, focusing on two main themes; our technological and educational possibilities from Norway to influence the health situations in low-and middle income countries, and opportunities to meet other researchers and teachers.

NTNU’s vision «Knowledge for a better world» and the medical faculty’s vision «Health for a better world» is comprehensive and relevant to the global world we live in, in Trondheim and elsewhere. Last but not least, I would like to thank all for the warm reception I have received in my new inspiring job.