Vol.3, No.1, 1-11 (2013) Open Journal of Preventive Medicine
Healthcare providers’ perceptions on screening for
Intimate Partner Violence in healthcare: A qualitative
study of four health centres in Uganda
Stephen Lawoko1,2*, Gloria K. Seruwagi3, Iryne Marunga4, Milton Mutto4, Emmanuel Ochola5,
Geoffrey Oloya6, Joyce Piloya7, Muhamadi Lubega8
1Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden;
*Corresponding Author : Stephen.lawoko@ki.se
2Makerere University, Kampala, Uganda
3Victoria University, Kampala, Uganda
4Pincer Group International, Kampala, Uganda
5Lacor Hospital, Gulu, Uganda
6Anaka Hospital, Gulu, Uganda
7Gulu Referral Hospital, Gulu, Uganda
8Iganga Hospital, Iganga, Uganda
Received 20 September 2012; revised 25 October 2012; accepted 5 November 2012
The current qualitative study explored the per-
ceptions of healthcare providers on screening
for Intimate Partner Violence (IPV) in healthcare
in Uganda, to develop a conceptual framework
for factors likely to hinder/promote IPV screen-
ing in the country. Using purposive sampling,
the study enlisted 54 healthcare workers (doc-
tors and nurses) from four hospitals (i.e. Gulu
referral hospital, Iganga referral hospital, Lacor
hospital, Anaka hospital) to participate in eight
focus group discussions. Data was thematically
analysed using Template Analysis. The study
found support for an ecological framework
suggesting a complex interaction of factors at
the individual (e.g. poor skills in detection of IPV
by health workers and unwillingness to disclose
abuse by patients), organisational (e.g. under-
staffing and lack of protocols for IPV screening)
and societal (e.g. societal acceptance of abuse
of women and poor policy on IPV management)
levels as potential barriers to the practice of IPV
screening in healthcare Uganda. These findings
have important implications on further training
of healthcare workers to adequately screen for
IPV, re-organisation of the healthcare system so
that it is fully-fledged to accommodate IPV scree-
ning and improved collaboration between the
health sector and other community advocates in
IPV management. These initiatives should run
concurrently with a concerted community sen-
sitization effort aimed at modifying attitudes
towards IPV among care providers and recipi-
ents a like, as well as preparing the general
population to will-fully disclose IPV to health-
workers. Study limitations and implications for
further research are discussed.
Keywords: Intimate Partner Violence; Screening;
Healthcare; Perceptions; Uganda
Intimate Partner Violence (IPV), defined as behaviors
within an intimate relationship that cause physical, sex-
ual or psychological harm, including acts of physical
aggression, sexual coercion, psychological abuse and
controlling behaviors [1], remains a global health prob-
lem among women. Despite the inaction of laws and
policies to manage Intimate Partner Violence in several
countries, IPV prevalence remains alarmingly high glob-
ally, with devastating short and long term consequences
on women’s health. With small cross-country variations,
prevalence of IPV ranging between 3% - 38% have been
reported [1-3], and many of the victims exhibit health
and behavioural complications manifest in severe physi-
cal injuries, depression, anxiety, post-traumatic stress
disorder, suicidal ideation, unhealthy feeding habits,
substance abuse and alcoholism [1-8]. Furthermore, vic-
tims of IPV in their reproductive age evidence termi-
nated pregnancies, undesired pregnancies and child loss
during infancy to a higher degree than peers in non-vio-
lent intimate relationships [1,8,9]. Thus, IPV does not
only impact on abused women’s health per se, but is
also associated with a poor foetus prognosis and infant
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S. Lawoko et al. / Open Journal of Preventive Medicine 3 (2013) 1-11
Despite the poorer health outcomes, IPV victims un-
der-utilize healthcare services and exhibit poorer bond-
ing with healthcare providers [9,10], when contrasted
with other healthcare users in general. These findings
have important implications for further adaptation of the
healthcare system to a more “user-friendly” system for
abused women. Screening for IPV is seen as a step in
that direction.
Screening for IPV in healthcare requires the system-
atic involvement of healthcare workers in the detection
of IPV among clients who may or may not present with
direct signs of victimization/abuse [11]. The discussion
on whether or not the practice of inquiry about the possi-
bility of IPV among all women visiting healthcare re-
gardless of the reason for their visit (i. e. universal
screening) is on-going, despite reports underscoring the
significance of such practice. First, anecdotal evidence
suggests that merely recognising and validating a bat-
tered woman’s situation may have far reaching effects on
her response to treatment and ultimately her health [11].
Second, healthcare professionals acknowledge that rou-
tine screening is likely to improve identification of IPV
[12]. Reciprocating this view, female patients visiting
healthcare report increased satisfaction with care, when
the issue of IPV is incorporated in health inquiries [13].
A consensus between the stakeholders notwithstanding,
only between 8% - 10% of healthcare personnel rou-
tinely screen for IPV [14,15], suggesting the presence of
barriers. The reasons for this discrepancy have over the
past decade received increased attention and can be
characterised under factors incumbent in care consump-
tion, care provision, care system and society at large.
Among female care consumers, the lack of willingness to
disclose abuse poses significant threat to effective
screening for IPV. Despite the fact that IPV accounts for
significant portion of the total care burden [9,16-20],
data from low, middle and high income societal contexts
suggest that between 20% - 70% of women are hesitant
to disclose abuse to formal institutions including health-
care [1,21-24]. Pertinent reasons why women may not
disclose IPV include the perceived lack of confidentiality
and inappropriate methods of inquiry from care providers
[25]. Moreover, women in some societies (e.g. low in-
come countries) appear to endorse IPV in certain cir-
cumstances, raising important questions as to whether
such women would see the significance of IPV screening
in healthcare. Studies have for instance found women in
Sub-Saharan African countries to endorse wife abuse for
reason including failures in her normative domestic roles
such as cooking and childcare [26,27]. Among care pro-
viders, insufficient knowledge and training in screening
could explain the poor frequency in IPV inquiries
[28-30]. In addition, professional roles governing the
provider-client relations (e.g. mutual respect, fear of of-
fending clients etc.), healthcare provider’s individual
attitudes towards IPV and cultural values could conflict
with IPV inquiry in healthcare [31,32]. At the organisa-
tional level, lack of clear policy surrounding IPV man-
agement, environmental factors (e.g. privacy in the wait-
ing room, length of wait for the service and lack of con-
tinuity of service), and poor availability of protocols for
the purpose render the practice of screening difficult
In summary therefore, a number of factors at the indi-
vidual, organisational (care system) and community level
appear to affect IPV screening in healthcare. Wh ile there
is a myriad of data to support these conclusions, re-
searchers acknowledge that some of these factors may be
context specific and may not be exhaustive of barriers to
screening for IPV in all contexts [32,35], drumming for
an in-depth analysis of each unique context.
Qualitative methods have long been proposed as ideal
for an in-depth understanding of health attitudes, knowl-
edge and behaviours. Using broad open-ended and in-
terconnected questions, the researcher aims at attaining
in-depth insight into an area of interest [36,37]. Though
much is now known about the factors that may foster or
hinder IPV screening in healthcare in the high income
countries, analysis of such factors in new contexts (e.g.
low and middle income countries) may exhibit a set of
new factors, while not refuting those already known and
could be universal. Given such circumstances, template
analysis, a qualitative approach, is the preferred tool.
This analysis takes into account already existing knowl-
edge in the field, while leaving room for new knowledge
to emerge. Further, the method is flexible to refute the
application of already existing knowledge to the new
context studied (see methodology section for more de-
In this paper, we sought an in-depth understanding of
the views of health care providers in Uganda about
screening for IPV, to develop a conceptual framework
for factors likely to hinder/promote IPV screening in
healthcare in Uganda. Such data is deemed important for
incorporation in any training program to improve care
providers’ readiness to screen for IPV. More precisely,
the study attempts to answer the following broad ques-
1) What are the views of healthcare providers in
Uganda rega rd ing IPV in general in Uganda.
2) What are the views of healthcare providers in
Uganda rega rding screenin g for IPV in healt hcare?
3) What do healthcare providers in Uganda identify as
factors that may hinder/promote IPV screening in health-
care Uganda ?
The care-providers views/perceptions will be sought in
regard to the following actors 1) health consumer; 2)
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S. Lawoko et al. / Open Journal of Preventive Medicine 3 (2013) 1-11 3
health provider; 3) health system; 4) any other party that
may emerge during the discussion.
2.1. Sampling, Procedures and Participants
This study uses qu alitative methods to und erstand care
providers views and perceptions on screening for IPV in
healthcare Uganda. It is part of a larger study comprising
both quantitative and qualitative methods to explore pos-
sible hinders and enablers of screening for IPV in
healthcare Uganda.
The primary method of data collection used in this
qualitative arm of the larger study was focus group dis-
cussions (FGDs) with frontline health workers. Pur-
posive sampling was undertaken to enlist 54 participants
from four (4) hospitals (i.e. Gulu referral h ospital, Ig an g a
referral hospital, Lacor hospital, Anaka hospital) in eigh t
(8) focus group discussions. The inclusion criteria were
being an enrolled or registered nurse and doctor. These
staff cadres where of interest mainly because of their
daily interaction with potential IPV victims and their
potential integral role in addressing the IPV problem
through a screening in terven tion, being at the forefront of
care provision. Exclusion criteria were being other health
worker with little or no interaction with potential victims
of violence. Semi structured focus group discussion
guides were used to elicit information that would answer
the underlying research question on health worker per-
ceptions and attitudes towards IPV screening. Separate
FGDs were held for each staff cadre and hospital respec-
tively. The FGDs were led by trained moderators and in
English, the official language in the country. Discussions
were audio-recorded following consent of the partici-
The data collection process, including the sampling
procedure, was based on the need to meet the study’s
primary objective which was to “assess healthcare pro-
fessionals attitude towards and perceptions about IPV
Results were discussed on a regular basis by all au-
thors as they emerged. Thus all authors provided vital
input for the discussion of this work .
2.2. Data Analysis
Data were thematically analyzed using the template
analysis (TA) approach [38,39]. Template analysis is an
adaptation of thematic analysis in qualitative research
and has been successfully applied in the field of qualita-
tive research with human subjects in several studies
[40-43]. The continued use of Template Analysis to in-
terpret textual data demonstrates its applicability, effi-
cacy and ease of usage in a variety of fields. In addition,
Template Analysis has been commended for its flexibil-
ity as shown below:
…the template approach allows codes and categories
to be presen ted hierarchically to aid the analytical pro c-
ess in categorising and unitizing data ...while bearing
some resemblance to grounded theory, template analysis
is less prescriptive and more flexible in its approach to
analysis, allowing the researcher to amend its use to the
needs of the research project...the template analysis in-
troduces structure and consistency into the categorising
and unitizing of qua litative in-depth in terview transcripts
[41, cited in 40].
Other studies [43] that have used template analysis
have concurred with this view that in comparison with
grounded theory, template analysis is more flexible and
easy to adapt “without necessarily applying puristic in-
ductive procedures and it also offers the prospect of de-
veloping broad conceptual themes which can be clus-
tered into broader categories” [40].
The method is particularly useful to study phenomena
for which broad themes have already been determined.
For instance, with regard to IPV screening, it is known
that factors likely to hinder/promote IPV screening in
healthcare are likely to be traced to individual, system
and societal factors (see introduction for a literature re-
view). This ecological structure thus formed the main
themes, from which subsequent smaller levels can be
The main strategy in TA thus is to determine the main
themes and derive subsequent smaller level themes in a
nested but orderly hierarchical way [38]. The coding
template therefore incorporated a number of broader
themes a priori which were strongly expected to emerge
from the focus group discussions (i.e. in accordance with
the ecological model). However, these themes and re-
lated codes were subject to modification.
Following identification of a priori themes and their
codes, all transcribed focus group discussions were read
through and match ed to the research questions and exist-
ing thematic codes. After reading through and marking
all the transcripts then this template was applied to the
whole dataset and transcripts which were th en coded to it.
This modified and all-inclusive template was then used
as the basis for interpretation, analysis and writing up of
the research findings. The initial coding template was
developed using information from the research questions
and FGD guide which were developed prior to the com-
mencement of fieldwork. In its development, we were
cognizant of new emerging themes that were not origi-
nally anticipated an d these were incorporated in the cod-
ing template as the FGD transcripts were read through
and assigned to (either a priori or new) codes.
Whilst Template Analysis was used to guide analysis
this study was aware that it is only a helpful tool for or-
ganising data. Actual interpretation of the data was
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S. Lawoko et al. / Open Journal of Preventive Medicine 3 (2013) 1-11
guided by the aims and objectives of this study, the
guiding research questions, as well as the researchers’
epistemological position and assumptions.
2.3. Ethical Considerations and Approval
For all participants informed Consent was given. Par-
ticipants were informed of the nature of the research
(goals and objectives, etc.), of the research methodology
to be used, of any risks or benefits, of their right not to
participate and /or to terminate participation at any time.
In addition, anonymity and confidentiality were empha-
sized. The study was approved by the Makerere Univer-
sity Research Ethics Committee and the Uganda National
Council for Science and Technology, the two bodies re-
sponsible for ethics in scientific research in Uganda.
3.1. Views on IPV in General
Health workers generally associated IPV with domes-
tic violence and observable physical harm in particular.
The most common forms of IPV they confronted in
healthcare were physical violence and sexual abuse, in-
cluding marital rape. In some cases it involved extreme
cases of murder as shown in the excerpt below:
The most common forms of IPV we come across are
domestic violence mainly between husbands and wives,
and forced sex between lovers when one party is not in
agreement (Doctor, Anaka).
It is physical fighting between lovers, sometimes…
killing of the whole family (Nurse, Anaka).
Men are being beaten these days but still the most
common one is the women being beaten (Nurse, Gulu).
We usually know at the time of treating injuries…es-
pecially when people have police forms or severe bruises,
or they seem emotionally unstable (Nurse, Anaka).
As shown in the excerpts above, health service pro-
viders used a clinical lens to conceptualize IPV. Their
understanding was directly related to their clinical duties
at the frontline and was closely linked to the responses
that victims required at health facilities in the aftermath
of IPV such as treatment for injuries incurred.
IPV was found to be larg ely engendered with men be-
ing the main perpetrators against women although
women were also noted to inflict violence on their part-
ners. Evolving trends in IPV were also noted by health
workers particularly abdication of family roles by men
and women inflicting violence on men.
Adultery for women is punishable but not for men
(Doctor, Iganga hospital).
Husbands ignore mothers and their children and even
use guns which was not the case back then (Nurse,
Iganga hospital).
Things are changing…there are also women who bat-
ter their husbands and send them away from their own
homes (Doctor, Lacor hospital).
It comes in form of misunderstanding of women by the
men most especially the nurses as their husbands think
they dont want to give birth (Nurse, Iganga hospital).
The excerpts above show that IPV is disproportion-
ately experienced by women compared to men and this is
largely due to perceptions that are rooted in sociocultural
values in patriarchal societies that tend to favour men.
Whereas there was some awareness around linking IPV
to other subtle forms such as men abandoning their fami-
lies, this was blurred by more explicit forms of violence
such as wife beating and using guns.
Health workers attributed some of the IPV evolving
trends (e.g. women as perpetrators) to recent movements
such as women “emancipation” and the rights movement
which strains relationships and appears to challenged
long standing and deeply cherished cultural values of
female compliance to males as shown below:
Women emancipation has made women more confi-
dent and not respectful of their husbands (Doctor, Iganga
IPV occurred as a result of cultural tensions where
deeply valued norms and traditions were being chal-
lenged for example imbalance in the dynamics of power
at familial level as well as childbirth which was being
overlooked by women in pursuit, or as a result, of their
careers. It also shows the widespread nature of IPV as
health service providers are themselves victims. Health
care professionals are not immune to IPV an d in addition
to having a responsibility to address IPV issu e with their
clients, they are victims themselves. Some of the health
care professionals were upfront about their victim status
as seen from the excerpts below:
Even health workers are burdened. They are also vic-
tims of IPV (Docto r, Iganga).
In the case of marital rape we are all being raped as
women especially when a man comes home drunk then
starts forcing himself on you when you already resting.
In the end we may fight or I will get beaten because I will
not allow you to enter me. so in this case one is not al-
lowed to report (Nurse, Gulu Hospital).
This study found societal acceptance towards some
forms of IPV and it was noted that the lived experience
of some IPV victim is one of acceptance and positive
perceptions. The most commonly “acceptable” form of
IPV was found to be wife beating whose function was
delineated to be two-fold: In the first instance, wife
beating was interpreted as a sign of love and was well
received by some women:
Wife beating is culturally accepted. It is a form of dis-
cipline. Some women complain when their husbands
dont beat them because it is a sign of love (Nurse,
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S. Lawoko et al. / Open Journal of Preventive Medicine 3 (2013) 1-11 5
Anaka hospital).
Secondly, wife beating was also reported to be a disci-
plinary measure used by the head of the household
within a home setting:
It is acceptable for example a man beating a wife for
the wrong she has done. It is a way of correcting or
disciplining her (Doctor, Anaka hospital).
Some men use wife beating as a form of discipline to
the wife. This is acceptable if there is no in jury or not life
threatening…a man is entitled to discipline his wife
(Nurse, Gulu hospital).
Cultural beliefs were highlighted as a major reason for
IPV and it accounted for unabated levels of some IPV
forms such as the one mentioned above.
Fighting in some cultures is tolerated as its a sign of
love and some women are taken as property in the home
(Nurse, Iganga hospital).
Rape in marriage is so much tolerated in this commu-
nity because culturally when a woman is married, she is
expected to satisfy the man with sex at any time he wants
cause its the main reason for her getting married (Doc-
tor, Iganga hospital).
Beating a wife is tolerated in society, this is because
women have been made to be inferior, especially in
Acholi culture, they say, a mere woman”, you dont
have any say, so women have taken that saying to be
right. So for any slight thing you are beaten even in front
of your children. So it is accepted. (Nurse, Gulu hospital).
As shown in the excerpts some forms of IPV such as
physical violence and marital rape were found to be not
only accepted but also encouraged. Other key triggers of
IPV reported by discussants included poverty, high sex-
ual drive among men, ignorance, illiteracy, infidelity and
high risk behaviour such as alcoholism and substance
In Northern Uganda, IPV was also found to be as a
result of challenges of resettling former Internally Dis-
placed People (IDP) into their communities. It was clear
that scramble for land and meagre resources in the af-
termath of war had led to a number of conflict. Study
participants also reported that it is mainly women who
bore the brunt of the violence and injustice both from
their partners as well as their partners’ families as shown
After the war most cases nowadays are related to land
disputes, you find that a widow has come back to the
village and now wants to settle, bu t cannot get back their
land and the mans family tends to chase away the
woman especially when they were not married they think
she has been away with oth er me (Doctor, Lacor).
Societal response to IPV cases were found to be weak
and not protective of the victims which partly accounts
for the lack of willingness on the part of the victims to
disclose or report:
I will give you an example about my real sister. He
[husband] had a misunderstanding with the wife. The
woman had just delivered and the man wanted to have
sex. The woman refused and said I have just given
birth. The man sent away the woman with all the six
children. The womans brother called him to settle the
matter but he refused. When they reported him to police
the family and protection unit, the man was summoned,
and asked to take back his wife and children and take
care of them (Nurse, Gulu Hospital).
Police is not helping beca use they ask for money from
victims even when they cant afford. So they end up not
reporting because they dont have confidence in police
(Doctor, Iganga Hospital).
These days people rarely report so they die quietly
(Doctor, Lacor Hospital).
As shown above system inefficiencies were found to
have resulted into frustration and resignation on the part
of IPV victims and rendered them voiceless, further per-
petuating the cycle of IPV.
3.2. Views on Healthcare Workers Capacity
to Screen/Involvement in IPV Screening
Health workers assessed themselves as being capable
of providing IPV screening and their perception towards
the intervention was positive. Most discussants looked at
IPV as a legitimate issue that should be addressed. The
FGD excerpts from below shows this:
Health workers should screen for IPV and it should be
part of our main duties as there are many cases of IPV
(Nurse, Iganga hospital).
Screening IPV is necessary and it should be main-
streamed in the daily duties (Doctor, Iganga hospital).
Screening IPV is necessary and it should be part of
our routine work (Nurse, Anaka hospital).
Most of the health workers strongly felt that IPV
should be mainstreamed in health service service deliv-
ery with dedicated resources and spaces in the hospital.
However, a few of th e health workers thought that refer-
ral services could be offered from the hospitals where
IPV victims are sign-posted to specialist areas. This
study found that some of the health facilities had inter-
ventions in place to respond the IPV problem, for exam-
ple Anaka Hospital has a unit for sexual gender based
violence (SGV). However these were reported to be lim-
ited in scope and frequency as shown in the excerpt be-
IPV is only screened when a patient has got physical
signs of violation and those with police cases (Doctor,
Iganga hospital).
It is done occasionally, through history taking because
sometimes they [victims] come with police forms (Doc tor,
Anaka hospital).
As nurses, screening is done but not as part of our du-
ties and this is not frequent, it is only done when there
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S. Lawoko et al. / Open Journal of Preventive Medicine 3 (2013) 1-11
are signs of violence but these cases are not followed up
because we have no upper hand in settling the matters
(Nurse, Iganga hospital).
As with most legal systems, in Uganda a physician’s
report is a mandatory requirement for some court cases
such as those involving sexual abuse. Therefore health
workers find themselves compelled to intervene at that
level although it may not be part of their mainstream
As a result of their continued interface with IPV vic-
tims, most of the health workers believed that they were
competent and had the skills to screen for it. Some of the
health workers had acquired relevant skills as part of
their professio nal de vel opment:
We screen but we lack training in IPV, however some
clinical officers have been trained in handling SGV vic-
tims (Doctor, Lacor hospital).
We have the capacity …the hospital has a special unit
in place though they need more human resources (Doc-
tor, Anaka hospital).
Despite their positive attitudes towards screening for
IPV the study participants were cognizant of their own
limitations, particularly those related to the system and
also other stakeholders involved such as victims, the
communities within which they are embedded and other
specialist workers. There were varied opinions regarding
disclosure level and the general perception was that dis-
closure levels among IPV victims were found to be gen-
erally low. However, health workers also reported that
victims, especially women, were increasing trusting health
workers and disclosing, depending on the magnitude of
the injury, in order to obtain help. This is in spite of the
deep rooted fear and possible repercussion of their dis-
IPV victims never disclose and until the health worker
sees a physical sign of violence then one can be asked
and some of them still cant tell you what happened as
they fear to be punished back home (Doctor, Iganga hos-
They disclose to health worker. The y are usually open
to health workers more than anybody (Doctor, Gulu hos-
The involvement of health workers is no solution be-
cause the communities are not aware of these IPV dan-
gers so they may not stop them unless sensitized (Nurse,
Iganga hospital).
The problem with Ministry of Gender is they develop
policies but they dont implement or they dont sensitize
the people then they just bring the policies to impose
them on the people (Doctor, Anaka hospital).
3.3. Views of Healthcare System Capacity to
Screen/Involvement in IPV Screening
At the individual level health workers were upbeat
about screening for IPV. However they are also aware of
the key role played by other stakeholders at the individ-
ual, household, community and national level which
could have a significant impact on the efficacy of their
intervention, as indicated in the above excerpts. A dis-
connection across these different levels and actors was
cited as a major constraint to IPV screening.
The general consensu s among this study’s participants
was that, despite health workers the health system had
very limited capacity to effectively support IPV screen-
ing. The reason for this is not only lack of infrastructure
but also resources in terms of time, human resources, and
We are competent but not supported by the health sys-
tem. We have the capacity however we lack time (Doctor,
Gulu hospital).
The services are inadequate (Nurse, Anaka hospital).
We lack equipment to do IPV screening (Doctor,
Iganga hospital).
3.4. Conceptual Framework of Factors That
May Hinder/Promote IPV Screening in
Healthcare Uganda
Discussants mentioned a number of factors that may
deter/promote IPV screening. Congruent with the tem-
plate used for this analysis, these factors appeared to
follow a socio-ecological framework (Figure 1), where
individual, care system and community/societal level
factors were paramount.
3.4.1. Individual-Level Factors
Poor disclosure: Discussants’ responses suggested that
poor disclosure of abuse was to expect from clients.
However there were implications in their statements that
further probing by care providers was likely to lead to
disclosure as pointed out in the ex cerpts below:
IPV victims never disclose and until the health-worker
sees a sign of physical abuse, then one can be asked and
some of them still will n ot answer as they fear to b e pun-
ished back at home (Doctor, Iganga hospital).
Victims disclose to health-workers mostly when they
come for treatment of IPV injuries (Nurse, Lacor hospi-
They (women) all dont open up. However, sometimes
the women blame the men yet they are the cause of the
problem (Doctor, Gulu hospital).
Sometimes when they report, they are not sure you will
give them a solution, so there is need to see how best to
address the perpetrators of violence and what best ways
to address the issue (Doctor, Anaka hospital).
Victims do not disclose, unless the health-worker
probes further about the issue (Nurse, Gulu hospital).
As suggested in some of the excerpts above, it ap-
Copyright © 2013 SciRes. OPEN ACCE SS
S. Lawoko et al. / Open Journal of Preventive Medicine 3 (2013) 1-11
Copyright © 2013 SciRes.
Figure 1. Model demonstrating factors that may hinder IPV screening in healthcare.
They (health-workers) need to be equipped with more
knowledge and skills on IPV Screening (Nurse, Lacor
peared that IPV inquiry was often related to an observ-
able injury. Moreover, in some responses there was a
tendency by providers to blame the victim. Fear of re-
taliation from the abuser, levying the blame on the victim,
and uncertainty regarding ability of healthcare work ers to
address the problem were some of the identifiable rea-
sons for poor disclosure of/probing for IPV.
3.4.2. Care System/Organisational Factors
Understaffing, lack of time and protocols: Partici-
pants’ responses indicated that under-staffing and lack of
time could impact negatively on IPV screening, as sug-
gested in the excerpts below. In addition, a lack of pro-
tocols for the purpose of screening and a weak support
network were highlighted at the system level.
Poor skills and information on IPV: Poor skills in in-
quiry about IPV and a lack of information on IPV causes
and management among care-providers were identified
as potential barriers to IPV screening at the individual
level as indicated in the responses below: Health workers feel confident to screen, but we are
understaffed (Doct or , Anaka hospital ).
Health-workers need specific training in IPV screen-
ing (Doctor, Iganga hospital). There is inadequate human resource (for screening)
(Nurse, Ana ka hospital).
Health- workers are compe tent, but they have not been
equipped to screen for IPV, so there is no capacity and
they are not supported by the system (Nurse, Anaka hos-
They (health-workers) have the capacity to screen but
they lack time (Nurse, Lacor hospital).
We lack equipment to do IPV screening (Doctor,
S. Lawoko et al. / Open Journal of Preventive Medicine 3 (2013) 1-11
Iganga hospital).
Creating links between health system and law keepers
to find solutions to cases of IPV would be supportive in
our role (Nurse, Iganga hospital).
3.4.3. Community/Societal Level Factors
At the community level, participants identified poor
sensitization of community members, a culture of accep-
tance for IPV, a failure to coordinate efforts against IPV
among relevant stakeholders and lack of policies on IPV
management as crucial hinders to effective IPV screen-
ing, highlighted in the excerpts below:
All sectors in districts should pull efforts together and
sensitize the community on all forms of IPV, its causes
and consequences (Nurse, Iganga hospital).
The involvement of health workers is no solution be-
cause the communities are not aware of these IPV dan-
gers so they ma y not stop them un less sensitized (Doctor,
Iganga hospital).
Much as it is necessary to screen, so long as the cul-
tural issues remain and women remain inferior to men,
the screening will not be of gr eat help (Nurse, Gu lu hos-
Most women in society dont even know their rights
and they tend to be comfortable in their situation even
when they are being to rt ur ed (Nurse, Gulu hospital).
Policies should be put in place so that the law can take
its cause when people are battered (Nurse, Iganga hos-
Creating links between health system and law keepers
to find solution to cases (of IPV) would be supportive…
(Nurse, Iganga hospital).
Not taking the identified IPV cases up by higher au-
thorities like the police after screening and identification
by health-workers is very frustrating when nothing is
done to the perpetrators (Doctor, Lacor hospital).
The main objective of this qualitative stu dy was to ex-
plore and deepen understanding on the perceptions and
attitudes of healthcare professionals towards IPV scree-
ning, in order to develop a conceptual model for factors
likely to hinder/promote IPV screening in healthcare
Uganda. Congruent with what has been reported in quan-
titative studies [31,32,35] we found that a complex in-
teraction of factors at individual, organisational and so-
cietal levels may influence screening for IPV in health-
care Uganda, despite the fact that healthcare profession-
als were generally positive and supportive towards in-
terventions to screen for IPV in healthcare.
First, at the individual level, healthcare workers exhib-
ited a narrow conceptualisation of IPV and related it
mainly to physically observable phenomena. It is highly
likely that this constricted definition would negatively
impact on their capacity to effectively d etect and respond
to IPV. As key frontline workers in service delivery,
doctors and nurses therefore need to be supported to fully
unders t a nd both subtle and explicit manifestations of I P V .
In addition, poor knowledge of the epidemiology of IPV
and skills in its detection were reported to potentially
influence IPV screening. Related to poor skills, individ-
ual fears of addressing IPV with victims and perpetrators
were signalled in the responses. Moreover, healthcare
providers faced challenges of prompting unwilling pa-
tients to disclose exposu re to IPV. These factors coupled
by acceptance of IPV as a means to punish women who
transgress from societal gender norms at the individual
and societal lev els, potentially render the practice of IPV
screening difficult. Thus, it is important that before any
screening program is introduced in healthcare Uganda, a
comprehensive training package comprising understand-
ing of the conceptualisation and epidemiology of IPV,
the modalities involved in IPV screening per se, and
tackling patriarchal/gender biased attitudes among indi-
vidual care providers is warranted.
Secondly, at the organisational level, understaffing,
inadequate human resource and capacity for IPV screen-
ing were discussed by participants as potential h inders of
IPV screening, consistent with quantitative studies re-
ported in other dissimilar societal context like Nigeria
[32] and Sweden [35]. Recent statistics in Uganda [MoH
2011; 2009] have demonstrated an understaffing crisis in
the country’s health system of up to 50%, resulting in a
heavy workload and consequent poor service delivery at
the frontline. This, co upled by the quest from discussan ts
for incorporation of screening protocols and other mo-
dalities (e.g. strategy for perpetration management)
demonstrate a low level of system preparedness to re-
spond to IPV screening currently in Ugandan healthcare.
Whereas clinical and related skills are invaluable, health
workers need to be supported by an organisation that is
fully fledged to meet the demands of patients, including
IPV victims. Thus the implications of th ese results on the
re-organisation and resourcing of the healthcare arena
need not be over-emphasised if IPV screening is to de-
velop into an effective practice in Ugandan healthcare.
Participants reported seemingly major barriers to IPV
screening at the societal level. IPV was found to be
deeply entrenched in cultural practices, decision making
and resultant action in male hegemonic societies. In try-
ing to explore the places and relationships in which
women’s lives were embedded, it was found that such
societies invite oppressive monitoring and control on
women and these serve to further entrench the vulner-
ability of women. As a result of this cultural hegemony,
IPV becomes largely engendered at all levels of society
from interpersonal relationships to macro level decisions
Copyright © 2013 SciRes. OPEN ACCE SS
S. Lawoko et al. / Open Journal of Preventive Medicine 3 (2013) 1-11 9
on the same. It was perhaps not surprising that th is study
found casual “acceptance” of some form of IPV such as
occasional wife beating—even by healthcare profession-
als purported to advocate for IPV screening. Together
with previous findings from quantitative studies demon-
strating significant societal acceptance of abuse of wo-
men for “failure” in normative domestic roles [26,27],
these findings drum the need for a concerted awareness
campaign in the general population of the health and
societal defects resulting from IPV, as such education is
known to modify distorted attitudes and reduce practices
that are harmful to health such as IPV [44]. Also at the
societal level, discussants expressed concerns over a lack
of reliable referral services to which eventual IPV vic-
tims could be referred and drummed the need for coor-
dinated efforts between different stakeholders in society
and healthcare system if IPV screening in healthcare is to
be effective.
Implications for Practice, Limitations and
Further Research
In summary, this study provided valuable information
prior to the initiation of IPV screening in Uganda. It is
recommended that before a routine screening protocol is
introduced the following conditions are paramount in-
cluding: 1) comprehensive staff training addressing the
conceptualisation of IPV, its epidemiology and modali-
ties involved in screening is warranted. It is hoped that
such training may modifying individual health-workers’
attitudes towards IPV; 2) organisational changes re-
sponding to understaffing issues and availing clear and
comprehensive screening protocols for IPV are necessary;
3) awareness campaigns of the negative impact of IPV
on society e.g. health effects (running parallel with the
above recommendations) are crucial to modify attitudes
towards IPV in the society, as well as prepare the general
population to will-fully disclose IPV to health-work ers;
4) building a rigorous network between the healthcare
system itself and other community advocates in IPV
prevention may improve among others referral services
for IPV victims.
The limitations of the current study deserve some ac-
knowledgement. First, applicability of the findings to
Ugandan healthcare in general should be done with cau-
tion. The study was carried out in only 3 of the countries’
111 districts and in 2 of the 4 main regions of Uganda
(i.e. northern and eastern Uganda). However, in Uganda,
the structure, policy and activities of hospitals appear to
vary depending on whether the hospital is a regional,
district or other smaller care units. In that respect there-
fore, the findings could be seen to represent views on
IPV screening in referral and district hospitals in north-
ern and eastern Uganda. This notwithstanding, our find-
ings generated a conceptual framework for factors possi-
bly influencing IPV screening, hypotheses of which
could be tested using quantitative methods in future re-
lated research in Uganda. A Second limitation concerns a
possible lack of heterogeneity in the FGDs. We did not
perform mixed FGDs in heterogeneous groups of profes-
sionals (i.e. including both nurses and doctors). Though
this was initially planned for, it came to our attention th at
there remains a hierarchy in position b etween nurses and
doctors in Uganda. Thus, the nursing staff argued that
they were unable to discuss these issues freely in the
presence of doctors (assumed to be higher in hierarchy).
The consequences of the lack of heterogeneity in FGDs
with regard to staff cadre on the results thus are difficult
to predict. It is plausible that mixed groups could have
enriched the discussions, providing impetus for the
emergence of new themes otherwise undetectable in ho-
mogenous groups alone. Finally, the views of nursing
assistants, aides, midwives and other staff were not
sought in this study. Yet they are of importance in the
healthcare of potential victims of IPV. This o mission was
due to the lack of such cadres in some of the smaller
hospitals studied. Future research should find modalities
for incorporation of these groups, to achieve a holistic
view of healthcare providers’ perceptions on screening
for IPV in healthcare, Uganda. Moreover, the views of
other stakeholders particularly the potential victims and
perpetrators on IPV screening in healthcare call for a
separate study on its own right.
We are most grateful to the Swedish Council for Working Life and
Social Research (FAS) and the Marie-curie program for funding this
study as part of the COFAS program.
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