Caring for women subjected to violence: a WHO training curriculum for health care providers

Caring for women subjected to violence: A WHO training curriculum for health care providers. Revised edition, 2021 New mo dule s for hea lth man age rs Caring for women subjected to violence: A WHO training curriculum for health care providers. Revised edition, 2021 ISBN 978-92-4-003980-3 (electronic version) ISBN 978-92-4-003981-0 (print version) © World Health Organization 2021 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. 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Design/Layout: greenInk.co.uk Contents Facilitator’s Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Purpose and overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Getting started . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Orientation and introductions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Session 1. Understanding violence against women as a public health problem . . . . . . . . . . . . . . . . . . . . . . .17 Session 2. Understanding the survivor’s experience and how providers’ values and beliefs affect the care they give . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 Session 3. Guiding principles and overview of the health response to violence against women . . . . . .29 Session 4. Provider–survivor communication skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 Session 5. When and how to identify intimate partner violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 Session 6. First-line support using LIVES, part 1: Listen, Inquire, Validate . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40 Session 7. Know your setting: identify referral networks and understand the legal and policy context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 Session 8. First-line support using (LIV)ES, part 2: Enhancing safety and providing Support . . . . . . . . .49 Session 9. Clinical care for survivors of sexual assault/rape, part 1: history-taking and examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 Session 9a. Forensic examination (supplemental) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 Session 10. Clinical care for survivors of sexual assault/rape, part 2: treatment and care . . . . . . . . . . . . .61 Session 11. Documenting intimate partner violence and sexual violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64 Session 12. Care for mental health and self-care for providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66 Session 13. Addressing family planning and HIV disclosure for women subjected to violence (supplemental) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71 Session 14. Assessing health facility/service readiness (module for health managers) . . . . . . . . . . . . . . .74 Session 15. Strengthening service readiness: improving health workforce capacity (module for health managers) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77 Session 16. Strengthening service readiness: improving infrastructure for privacy, ensuring supplies (module for health managers) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .82 Session 17. Preventing violence against women (supplemental) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91 References and supplemental reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93 Annex 1. Training timings and sample agendas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95 Annex 2. Tips for training. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Annex 3. Reading materials and handouts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Annex 4. Supplies checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Annex 5. Providing feedback: responding to questions and role plays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Annex 6. Certificate distribution or ceremony (optional) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Annex 7. Tools for monitoring and evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Annex 8. Supplemental exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Annex 9. Overview of handouts and resources for exercises* . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Supporting materials (i.e. handouts, resources for exercises and slide deck) can be accessed online here: https://www.who.int/publications/i/item/9789240039803 Facilitator’s Guide CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 1 Acknowledgements This curriculum draws on the work of many people around the world dedicated to preventing and responding to all forms of violence against women and girls. WHO would like to thank all of those who contributed and who shared their training exercises and experiences, many of which have been incorporated into this manual. The curriculum was developed by WHO’s Department of Sexual and Reproductive Health and Research (SRH) (Avni Amin, Claudia García-Moreno and Megin Reijnders) in collaboration with WHO’s Regional Office for the Americas/Pan-American Health Organization (Alessandra Guedes and Constanza Hege). An initial draft was developed in collaboration with the Johns Hopkins Bloomberg School of Public Health and the University of Michigan: Myra Betron, Michele Decker, Nancy Glass, Zaynab Hameeduddin, Jane McKenzie-White, Sophie Morse and Vijay Singh. Earlier versions of the curriculum were piloted with health- care providers in Bahamas and Guyana (by JHU and PAHO), Myanmar, Namibia, Pakistan, Uganda, and Zambia (by WHO/SRH) and with midwives in East Timor by Angela Taft and Kayli Wild. SRH also used the materials in a training of trainers in Geneva in July 2018 and in a virtual training of health managers from 12 countries from East and Southern Africa in 2020. WHO/SRH thanks the consultants and interns who supported the initial organization of the curriculum development, Floriza Gennari, Erin Hartman and Thais de Rezende. WHO/SRH gratefully acknowledges the curriculum advisory board members for all their contributions and inputs throughout the development process and review of drafts: Kiran Bhatia, Jan Coles, Anne Catherine Deleon, Kelsey Hegerty, Lisa James, Ana Flavia Lucas d’Oliveira, Grace Mallya, Soroja Pande, Lourdesita Sobreyega-Chan, Jinan Usta and Silvie Lo Fo Wong. SRH also would like to thank the following individuals for their review of drafts of the curriculum: Anna Baptista, Jennifer Breads, Jovita Ortiz Contreras, Claire Mathonsi, Rose Olson, Caroline Rodriguez, Sarah Siebert, Angela Taft, Kusum Thapa and Kayli Wild. Sara Johnson and Ward Rinehart developed the structure and co-wrote the instructions for the exercises contained in the curriculum. CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 2 Purpose and overview Violence against women, including intimate partner violence and sexual violence, is pervasive globally and leads to significant physical and mental health problems. Thus, it is a public health issue that demands a concerted response from health-care providers and health systems worldwide. The World Health Organization (WHO) has developed guidelines for the health-care sector: Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines (2013) and an accompanying clinical handbook Health care for women subjected to intimate partner violence or sexual violence: clinical handbook (2014). This in-service curriculum, based on these documents, aims to provide health-care providers with the knowledge and basic skills to implement the WHO recommendations in their clinical practice. Training providers is key to improving the health system’s response to violence against women. This curriculum is designed to provide health-care providers, particularly in low- and middle-income countries, with a foundation for responding to domestic/ intimate partner violence and sexual violence against women. The curriculum seeks to build skills and to address providers’ attitudes towards survivors of violence. Participants will learn how to provide women-centred clinical care, including identifying women experiencing violence, providing first-line support though the LIVES approach (Listen, Inquire, Validate, Enhance safety and Support), providing essential clinical care for survivors, and identifying local support resources. They will learn to reflect on their own attitudes and understand survivors’ experience. The curriculum emphasizes compassionate, empathic provider–patient communication. This curriculum is based on WHO’s clinical handbook. Participants and facilitators are advised to keep the handbook handy for reference throughout the training. Training is an important component of an overarching health system response to violence against women. Health services managers and health policy-makers also have responsibility for strengthening planning, coordination and human resource management; establishing policies and protocols; and monitoring and evaluating the provision of care to survivors of violence. Four new modules have been added to the revised 2021 edition, while the earlier content remains unchanged. Three of the new modules are specifically targeted at health managers to assess and improve facility readiness, including capacities of the health workforce and infrastructure. One new module is aimed at both – providers and managers – to improve integration of prevention interventions into existing health services or interventions. Managers and policy-makers are advised to consult Strengthening health systems to respond to women subjected to intimate partner violence or sexual violence: a manual for health managers (WHO, 2017) for comprehensive guidance on improving health system readiness. The clinical guidelines on which this training is based do not specifically address children, adolescent girls (under age 18) or men. Nonetheless, actions described may also be valuable for these population. They also apply to domestic violence more broadly – that is, violence by family members other than an intimate partner. Facilitators are encouraged to review Responding to children and adolescents who have been sexually abused: WHO clinical guidelines (WHO, 2017) for recommendations for a child- and adolescent-centred response. Who is this training for? This training curriculum is primarily designed for practising health-care providers, particularly doctors, nurses and midwives. Parts of it may also be useful to other cadres of health-care providers, including psychologists, social workers, nurse assistants, community health workers and lay counsellors. Sessions 14–17 are also targeted to health managers. Participant-centred learning This curriculum uses a participant-centred approach to learning – an active, collaborative, inquiry-based approach to teaching and training. Also known as learner-centred education, participant-centred learning emphasizes that the trainee is an active participant. Participant-centred learning actively engages the trainee wherever possible, rather than relying only on facilitators. Learners actively participate in knowledge and skills First-line support L Listen, I Inquire V Validate E Enhance safety S Support CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 3 development through case studies, guided discussions, participatory reflection exercises, videos and readings. This process supports critical reflection, emotional engagement, skills development and the ability to put knowledge into practice. Competency-based training This competency-based curriculum enables development of the knowledge and skills to provide comprehensive, high-quality care to women who are subjected to intimate partner violence or sexual violence. Each session supports one of four objectives (see box) while fostering unique competencies. Table 1 presents the titles and competencies of the training sessions. The objectives and capacities for this training were defined through an expert review process. Aim of this training To foster understanding of and develop the basic skills to implement the recommendations of the WHO clinical and policy guidelines and clinical handbook on responding to intimate partner violence and sexual violence against women. The four objectives of the training 1. Demonstrate general knowledge of violence against women as a public health problem. 2. Demonstrate behaviours and understand values contributing to safe and supportive services for survivors. 3. Demonstrate clinical skills appropriate to one’s profession and specialty to respond to violence against women. 4. Demonstrate knowledge of how to access resources and support for patients and for oneself. Table 1. Sessions, objectives and competencies No. Session, objective, competencies 1 Understanding violence against women as a public health problem Objective 1. Demonstrate general knowledge of violence against women as a public health problem Competencies: ■ Know the epidemiology of the different forms of violence against women at global and local levels. ■ Know the health consequences of violence against women. ■ Understand the role and limitations of health-care providers in responding to violence against women. ■ Know about the WHO clinical and policy guidelines and clinical handbook on responding to intimate partner violence and sexual violence against women. 2 Understanding the survivor’s experience and how providers’ values and beliefs affect the care they give Objective 2. Demonstrate behaviours and understand values contributing to safe and supportive services Competencies: ■ Demonstrate self-awareness of one’s beliefs, assumptions, potential biases and emotional responses that can affect interactions with survivors of violence against women. ■ Understand the circumstances and the barriers that women experiencing violence face when seeking support. ■ Recognize the importance of having empathy with survivors. 3 Guiding principles and overview of the health response to violence against women Objective 2: Demonstrate behaviours and understand values contributing to safe and supportive services Competencies: ■ Know the guiding principles of providing woman-centred care in a culturally appropriate way. ■ Understand how to apply the guiding principles for women-centred care in your practice. CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 4 No. Session, objective, competencies 4 Provider–survivor communication skills Objective 2: Demonstrate behaviours and understand values contributing to safe and supportive services Competency: ■ Communicate empathically and effectively with patients/survivors. 5 When and how to identify intimate partner violence Objective 3: Demonstrate clinical skills appropriate to one’s profession and specialty to respond to violence against women Competencies: ■ Understand the minimum standards that need to be met to enquire about and respond appropriately to violence against women. ■ Recognize the signs and symptoms that suggest intimate partner violence. ■ Understand when and how to ask about intimate partner violence. ■ Demonstrate appropriate ways to ask about intimate partner violence. 6 First-line support using LIV(ES), part 1: Listen, Inquire, Validate Objective 3: Demonstrate clinical skills appropriate to one’s profession and specialty to respond to violence against women Competencies: ■ Know the content of first-line support (LIVES). ■ Demonstrate skills in offering the first three elements (listening, inquiring and validating) of first- line support to survivors who disclose abuse. 7 Know your setting: identify referral networks and understand the legal and policy context Objective 4: Demonstrate knowledge of how to access resources and support for patients and for oneself Competencies: ■ Understand the role of other services in caring for survivors of violence against women. ■ Know what resources are available in the community. ■ Know the legal and policy context, including health-care providers’ legal obligations, with regards to the local and national response to violence against women. 8 First-line support using (LIV)ES, part 2: Enhancing safety and providing Support Objective 3: Demonstrate clinical skills appropriate to one’s profession and specialty to respond to violence against women Objective 4: Demonstrate knowledge of how to access resources and support for patients and for oneself Competencies: ■ Demonstrate the skills to assess immediate risk/safety and to support safety planning. ■ Know what resources are available in the community. ■ Know how to collaborate with partners to help survivors access other services and to provide referrals. ■ Demonstrate skills to provide warm referrals. 9 Clinical care for survivors of sexual assault/rape, part 1: history-taking and examination Objective 3: Demonstrate clinical skills appropriate to one’s profession and specialty to respond to violence against women Competencies: ■ Demonstrate skills to take a clinical history. ■ Know how to conduct an examination of a survivor of sexual assault, including rape and abuse. ■ Know when to collect forensic evidence and how to support or facilitate such evidence collection. CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 5 No. Session, objective, competencies 9a Forensic examination (supplemental) Objective 3: Demonstrate clinical skills appropriate to one’s profession and specialty to respond to violence against women Competency: ■ Know when and how to collect forensic evidence. 10 Clinical care for survivors of sexual assault/rape, part 2: treatment and care Objective 3: Demonstrate clinical skills appropriate to one’s profession and specialty to respond to violence against women Competency: ■ Know how to provide appropriate treatment/care to survivors of sexual assault, including rape and abuse. 11 Documenting intimate partner violence and sexual violence Objective 3: Demonstrate clinical skills appropriate to one’s profession and specialty to respond to violence against women Competency: ■ Know how to document violence against women in a safe and confidential manner. 12 Care for mental health and self-care for providers Objective 3: Demonstrate clinical skills appropriate to one’s profession and specialty to respond to violence against women Objective 4: Demonstrate knowledge of how to access resources and support for patients and for oneself Competencies: ■ Know how to provide basic mental health care. ■ Know how to access and practise self-care. 13 Addressing family planning and HIV disclosure for women subjected to violence (supplemental) Objective 3: Demonstrate clinical skills appropriate to one’s profession and specialty to respond to violence against women Competency: ■ Demonstrate skills in identifying and caring for women experiencing violence who present to either family planning or HIV services. 14 Assessing health facility/service readiness (module for health managers) Objective 2: Demonstrate behaviours and understand values contributing to safe and supportive services Competency: ■ Assess how to improve service quality and create an enabling environment for service delivery 15 Improving health workforce capacity (module for health managers) Objective 2: Demonstrate behaviours and understand values contributing to safe and supportive services Competency: ■ Facilitate training, supervision and mentoring of health-care providers CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 6 Time requirements The curriculum is designed for flexible implementation. The full 13 sessions are usually delivered in two and a half days, and experience suggests that this is the minimum required. However, if necessary you can cover sessions 1–12 in two days. To cover the core content adequately, a minimum of two continuous days is needed. However, additional time to practise skills is desirable, particularly for participants who are learning about this issue for the first time. If less than two days are available, you will need to adjust the content to fit the time available. We suggest covering sessions 1 through 8 to ensure that LIVES is fully covered. Additional skills-building exercises are provided in case more time is available. If the time is available, it would be best devoted to practising skills in first-line support, which is central to survivor- centred clinical care. Health managers should, at minimum, cover sessions 1 to 7, 11 and 14–16 over a period of 8–9 hours. Alternatively, the core content can be covered by half- day sessions scheduled at regular intervals over several weeks or months. This low-dose, high-frequency approach has proved effective for training. While we recommend a minimum of 12–14 hours, if there is less time available, much can still be accomplished by keeping the focus on skills in offering first-line support. Some settings have come back for remaining or repeated sessions six months later as part of a refresher. If necessary, some skills-building can also happen within half- or one-day sessions. Annex 1 shows the time suggested for each session, with and without supplemental content. This schedule may vary according to context and local preferences. If preferable, more time can be devoted to sessions that involve role play, including sessions 6 and 8. Care should be given to the spacing and delivery of content to ensure that participants practise and master new skills before learning more skills. Learning is a continuous process. Refresher sessions at regular intervals (for example, annually) will help providers to consolidate and update their knowledge and skills. Need to take this training alone? This facilitator’s guide is best used in a classroom or group setting. If you are alone, identify at least one additional trainee to do the training with you. Be sure to think through the reflection questions, either alone or with a training partner, to obtain the most from your training experience. An e-learning version will be available in mid-2020 and is meant to be self-guided. No. Session, objective, competencies 16 Improving infrastructure for privacy, ensuring supplies (module for health managers) Objective 2: Demonstrate behaviours and understand values contributing to safe and supportive services Competency: ■ Planning to improve infrastructure and procurement of equipment and supplies 17 Preventing violence against women (supplemental) Objective 3: Demonstrate clinical skills appropriate to one’s profession and specialty to respond to violence against women Competencies: ■ Understand how to enhance protective factors, minimize risk and mitigate harmful consequences of violence against women ■ Know about multisectoral prevention strategies that the health sector can promote or advocate with other sectors ■ Identify prevention strategies that can be implemented by health-care providers/settings CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 7 Who should be trained? The training is designed for a group setting, to harness the group experience for critical reflection and support for adaptation and implementation of content to the local context and service delivery structure. Ideally, this training should be implemented with groups of different types of health-care providers from the same facility – doctors, nurses/midwives, those with administrative/supervisory responsibilities). Different providers have different roles and responsibilities in providing care and, hence, need to learn to communicate and work as a team to deliver quality care. Sessions 1 to 7 and 11 should also be conducted together with health managers from the same facilities. Some trainings have also included police and other sectors. Participatory training is more effective with small groups of participants. Ideally, 20–30 participants would be trained at a time to allow adequate time for discussions and interactive activities. However, the same content can be delivered with a larger group. Participants from other sectors While a large part of this training is designed specifically for health-care providers, there are sessions where it may be particularly useful to invite participants from other sectors, such as the police, judicial and social services, and organizations that work with communities. A multisectoral training can help ensure that all participants share a common understanding of what is required to meet the health- care needs of survivors in a timely way, what health- care providers can and cannot do with respect to medico-legal care, how to strengthen coordination and referrals and how to mobilize communities to support survivors. In Annex 1 the symbol # indicates a session where participants from other sectors can be especially helpful. Plan the training venue in a way that allows space for additional participants. This facilitator’s guide This document is a facilitator’s guide to the curriculum. It provides directions on how to implement this training for maximum learning. ■ Follow the facilitator’s guide. This curriculum was developed with input from experts and trainers and underwent several pilot tests. It was developed keeping in mind facilitators with variable knowledge of violence against women and violence against women experts with variable knowledge of facilitation. Please follow the facilitator’s guide to ensure that the main points are learned, and the recommendations are followed. Those with long experience facilitating training on the health response to violence against women will be able to use their experience to provide additional examples and insights for the learners. ■ Implementation notes and tips on facilitation for trainers are included in each session. They are intended to foster active, participant-centred learning. ■ Notes accompany many of the slides and provide additional information for facilitators to communicate content. ■ The sessions are ordered to move systematically from building an understanding of the problem and women’s context through cumulative skills- building. This structure makes depth possible and reinforces the application of knowledge and skills learned in earlier sessions. ■ The sessions are structured so that facilitators can: ■ deliver key content and information clearly and concisely ■ facilitate participatory learning through a range of interactive methods (for example, role plays, video demonstrations, group discussions, brainstorming) ■ facilitate participants’ critical reflections on key learnings through guided discussions ■ summarize key messages for each session. CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 8 Getting started Who should facilitate? The best facilitators for this training will have a combination of the following: ■ a clinical background (doctor, nurse, psychologist, counsellor) ■ experience providing health care to women survivors of violence ■ experience in training, including leading interactive discussions. Two facilitators are recommended. ■ Facilitators should alternate the lead and support roles described below to minimize fatigue and provide participants with variety in presentation styles. ■ If possible, at least one co-facilitator should represent a relevant local health facility to support institutional buy-in and allow setting-specific discussion of material, concepts and resources. ■ In some cases a single experienced facilitator can lead the entire training. If there are other experienced people in the group, they could be invited to play the support role. Lead facilitator’s role ■ Lead presentations of content and discussion ■ Circulate through the room during group work to monitor and provide feedback. Support facilitator’s role ■ Monitor time ■ Circulate microphone to participants as needed ■ Distribute case examples or written materials as needed ■ Identify questions in the group ■ Provide an additional perspective on questions raised in the group ■ Circulate through the room during group work to monitor and provide feedback on activities. Preparing for the training The checklist in Table 2 can help you prepare to conduct the training. CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 9 Table 2. Preparation checklist Know your trainees ■ Know your participants. Know the background and current job responsibilities of participants and, if they are members of a team, their roles on the team. ■ Acknowledge that some aspects of the content may be distressing for participants who have experienced violence in their own lives (see tips in Annex 3). Space, supplies and equipment ■ Meeting space and equipment. If possible, find a space where you can use equipment such as audiovisual aids. Equipment may include: ■ computer ■ projector ■ white board ■ microphone with adequate speakers/sound system if the size of the room requires it. ■ Provide a place to go. Find an additional room or other space where participants can go if they feel uncomfortable. There may be survivors of violence participating, and they may need to excuse themselves from time to time. ■ Set up ahead. Arrange the room before the course begins, and check equipment. ■ Provide tables. Set up the room with tables in small groups (6–8 persons) to allow maximum participation and discussion. Do not set up the room in lecture style with rows of chairs. Schedule, invite guests ■ Develop a schedule. Table 1 proposes the order of sessions, but the schedule can be modified based on available time, type and experience of participants and supplemental activities. ■ Allow time. If you need to change the suggested schedule, review the facilitator’s guide to ensure that sufficient time is allotted for discussions, exercises and breaks. ■ Invite guests. Consider if, when and how guests will be included as speakers or learners. See section on invited guests, next page. ■ Award certificates? Decide whether to award completion certificates. See the section on certificate distribution or ceremony (Annex 6, p. 90). Facilitator preparation ■ Materials. In advance, review all training materials, including facilitator’s guide, slides, slide notes and handouts. For each session this facilitator’s guide details key points to make. Questions and probing points for semi-structured discussion are provided. Give special attention to the step-by-step instructions for each activity. ■ Facilitators’ roles. Review and agree on roles and responsibilities in each session. ■ Essential reminders and tips. Review the essential reminders, Table 3, and tips for effective training, Annex 2. Prepare the materials and supplies ■ Prepare the participants’ reading materials and handouts (Annex 3). ■ Provide the clinical handbook and other WHO resource materials ahead of time. Have other materials ready to distribute at each session. ■ Print the reading materials and handouts to be distributed in hard copy. Copy onto USB keys any files to be distributed electronically. These keys can also be used for documenting any group work assignments. ■ Gather supplies (Annex 4). CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 10 Make the training relevant to your setting ■ Adapt training materials to the local context as necessary. For example, case studies, names of characters in story cards and role plays and visuals should all be adapted to local context. ■ Review terminology in the facilitator’s guide and the slides to ensure that terms suit the local context or modify as needed. ■ Consider adding a slide with country/regional data on violence against women to Session 1 (slide 10). ■ Review the legal and policy context, including laws and policies and protocols, regarding violence against women at the health setting that is hosting the training. These will be reviewed in Session 7. For example, a. Is there a protocol/standard operating procedure for service provision? b. Does the health information system have provisions for documenting violence – for example, facility registers or intake forms? c. What laws and policies affect confidentiality, reporting obligations and who can provide care or perform specific procedures? d. What, if any, are the circumstances under which abortion can be offered/provided? e. What, if any, are restrictions on providing treatment based on the age of the survivor or type of treatment? f. Which documentation form is used for cases of sexual assault including forensic examination? ■ Map support services (use the referral chart job aid in the clinical handbook as a reference). ■ Identify at least one support resource to mention at the beginning of the orientation session that participants could use if needed during training. ■ Consider showing videos and websites that take into account the safety of the participants, are culturally appropriate and do not involve inappropriate imagery. Guest speakers and resource persons This training can be enhanced with additional invited guest speakers or resource persons or participants from other sectors. Invited guest speakers can provide clarity on topics that may be beyond the expertise of the primary facilitators. Review with any guest speakers the learning objectives and competencies for the session that they will contribute to. You can invite, for example: ■ a provider or advocate who works with survivors of violence providing other types of services (for example, counselling, legal advice, shelter) to discuss what services are available and ways to strengthen referrals (see Session 7) ■ a legal expert to talk about the laws pertaining to violence against women and the legal obligations of health-care providers (see Session 7) ■ a representative of a non-governmental organization (NGO) or women’s organization that provides information to survivors about their rights and options for legal recourse (see Session 7). Policy-makers Senior policy-makers or health-care managers can play an important role by demonstrating political commitment to the response to violence against women in the health sector and inspiring health-care providers. Policy-makers can be asked to address the group about existing policies, programmes and budgets relevant to health care for survivors of violence. CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 11 Table 3. Essential reminders while training on care for violence against women Self-determination: the choice of the survivor is central. ■ Patient/survivor preferences and needs should guide the provision of all care. Whenever possible, remind participants that we trust the survivor to know what is best for herself and her situation. Be vigilant about identifying and responding to victim-blaming. ■ Make clear that violence is never a woman’s fault. Terminology matters. ■ This curriculum uses the term “survivor” rather than “victim” to indicate that the person who has experienced violence has agency, autonomy and choice and to mitigate stigma. What about violence against men? ■ The issue of violence against men often comes up in discussion. Clarify that: ■ Evidence shows that the forms and nature of violence faced by women and by men are different. ■ Violence faced by women is rooted in unequal gender power relations and is more likely to come from a close male partner or other family member (or within other trusted relationships) and to be hidden. ■ Skills learned in this training – particularly survivor-centred response and first-line support – can be useful for responding to male survivors. What about children? ■ Violence against children and adolescents may also come up in discussion. Sessions 9 and 10, on clinical care for sexual assault, cover specific considerations for children and adolescents. Sessions CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 13 60–80 minutes Exercise: Fear and Motivations in a Hat1 (30 minutes) ■ Copies of pre-training survey (optional) ■ Flip chart/large pieces of paper ■ Hat, bowl or basket (for Fear and Motivations in a Hat exercise) ■ Sticky notes or note cards and tape ■ Pens Provide pre-training survey for participants to complete, if using survey as part of training evaluation. Introduce yourself and other facilitators and resource persons, and briefly describe your backgrounds. Explain that we will begin with participant introductions and a brief discussion of the learning objectives for the training. Invite participants to form pairs with their neighbours. Ask the pairs to take 2–3 minutes to introduce themselves to their partners (that is, their name, what the name means or signifies in their culture, their clinical role and institutional affiliation). In plenary, depending on the number of participants and the time available, ask 3–4 pairs to introduce their partners to the rest of the group (1 minute per pair). Note: Even if participants already know each other well, this exercise to facilitate introductions is a useful icebreaker. Also, it gives the facilitator an opportunity to become Session length Training techniques Facilitator materials Pre-training survey (optional) (20 minutes) Introductions (10 minutes) Orientation and introductions Preparation and general information Session content Adapted from Kelsey Hegarty’s “Fear in a Hat.” CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 14 familiar with the participants. This is just an example, and you are encouraged to find other creative ways to facilitate participant introductions as appropriate in your context. As a result of this training, participants will be able to (slide 2): ■ Objective 1: Demonstrate general knowledge of violence against women as a public health problem ■ Objective 2: Demonstrate behaviours and understand values contributing to safe and supportive services ■ Objective 3: Demonstrate clinical skills appropriate to one’s profession and specialty to respond to violence against women ■ Objective 4: Demonstrate knowledge of how to access resources and support for patients and for oneself Training overview (slide 3) Review the agenda. Housekeeping. Orient trainees to the training space (for example, restroom location, safe/quiet space and other logistics). Expectations. Ask participants, “What are your expectations for this training?” Write the participants’ expectations on a flip chart or large piece of paper and display it at the front of the room. Review the list quickly so that you can refer back to it throughout the training. If any topics come up that are not covered, decide whether they can be reviewed within the planned agenda or if additional or separate training time is needed. Explain that the training format is a blend of didactic and participatory methods. Acknowledge the presence of survivors and encourage sensitivity. ■ For example: “I want to remind everyone that some of us may be survivors of violence ourselves. There may also be those who have witnessed such violence or had it happen to someone close to them. This is a reminder to all of us to be sensitive to those experiences during our time together.” Explain that some of the material presented may be triggering to participants who have experienced violence. Tell participants that they can step out if they are uncomfortable. Encourage them to engage in self-care as needed. Write down on a board or flip chart at least one resource that is available for survivors during the training and encourage its use should they need it. Ground rules. Explain that it is important to establish a set of ground rules for training. Ask people to suggest ground rules for the training. Write them on a flip chart. Present the overall learning objectives for the training (5 minutes) Presentation of the agenda and logistics (15 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 15 Probe for and add anything missing from this list (slide 4): ■ Timeliness – both in attendance and in expressing your point of view ■ Learn and work together ■ Contribute to meeting the objectives – participate actively, record workshop outputs, volunteer to lead/facilitate exercises ■ Respect each other ■ Listen with an open mind ■ Let everyone participate ■ Express disagreements respectfully ■ Give feedback in a constructive way (starting with the positive) ■ Do not interrupt when people are talking ■ Safe space ■ Respect confidentiality. Any personal information shared stays in the room ■ Be present ■ Only use electronic devices such as mobile phones or laptops for emergencies. Explain that these ground rules will govern the training and that additional suggestions can be made as the training progresses. Learning objectives for the exercise (slide 5) ■ To acknowledge and understand providers’ concerns about caring for survivors of intimate partner and sexual violence ■ To build on providers’ motivations and strengths in addressing intimate partner and sexual violence. Instructions for facilitators (slide 6) ■ Give each participant two pieces of paper. ■ Put out two hats or boxes for participants to put their notes in. Label one “Fears” and the other “Motivations”. ■ Ask participants to write: ■ on one piece of paper something that motivates them to respond to intimate partner or sexual violence ■ on a second piece of paper one fear that they have about responding to intimate partner or sexual violence. ■ Ask the participants to fold the pieces of paper and put them in the hats – fears in one, motivations in the other. ■ Randomly pick out a response from the “fears” hat and read it to the group. Discuss the fear with the participants and ask how such a fear can be overcome. ■ Do this two or three more times, depending on time. Exercise: Fear and Motivations in a Hat (30 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 16 ■ Next pick out a response from the “motivations” hat and read it to the group. Discuss the motivation with the participants and ask for suggestions of how the training can build on this. ■ Do this two or three more times, depending on time. ■ During a break, stick all responses on two separate flip charts (barriers/fears on one and motivations on the other), organized by broad themes/areas, to refer to throughout the training. (If time permits, it is useful to include a short session towards the end of the course to revisit them, see how many were addressed throughout the training and discuss others.) Take-away points (slide 7) ■ Many providers have concerns about raising the topic of violence with their patients. They may fear that this may trigger their own memories of experiencing or witnessing abuse, or they may feel inadequate to respond to violence. ■ However, data suggest that if providers raise the topic of violence with women and respond to them with empathy, this can be a source of healing for survivors. ■ Many of us are passionate about providing care and ensuring health and justice for our clients. This positive energy can fuel how we apply this training in our clinical practice. CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 17 Session 1. Understanding violence against women as a public health problem Preparation and general information Objective 1: Demonstrate general knowledge of violence against women as a public health problem. Competencies ■ Know the epidemiology of the different forms of violence against women at global and local levels. ■ Know the health consequences of violence against women. ■ Understand the role and limitations of health-care providers in responding to violence against women. ■ Know about the WHO clinical and policy guidelines and clinical handbook on responding to intimate partner violence and sexual violence against women. 40 minutes (Extra time may be needed for country presentations.) ■ Video (5 minutes) ■ Presentation with slides and discussion (35 minutes) ■ Violence against women: Global picture/health response ■ Addressing provider barriers to responding to violence against women ■ Why does the health-care provider response matter? ■ Violence against women is a major public health and women’s health problem. It is rooted in gender inequalities. It is a human rights violation. ■ Women subjected to violence have the right to the highest possible standard of health care. Health-care providers have an obligation to fulfil this right, and they are in a unique position to support women subjected to violence. They can create a safe and confidential environment for facilitating disclosure of violence and offer an empathic response, appropriate treatment and referrals to other resources and services. ■ We will start by watching a short video about strengthening the health system response to violence. Learning objectives and competencies Session length Training techniques Handouts Background Session content CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 18 Explain that we will now present a brief (3-minute) video. Present video from this link (slide 3): https://www.youtube.com/watch?v=Qc_GHITvTmI Slides for Session 1 cover the following content (for details, see the slide notes in the PowerPoint file): Definitions and forms of VAW (slides 4–6) ■ Read aloud the global definition (slide 5). ■ Violence against women takes many forms. Intimate partner violence (domestic violence) is the most common form worldwide (slide 6). ■ Ask participants to reflect on and discuss other examples of violence not listed, and what forms of abuse are most common in their setting and recognized by their legal framework. Prevalence of VAW (slides 7–12) ■ Distribute handout Violence against women: global picture/health response. ■ Highlight the global and regional estimates of intimate partner violence and sexual violence (slides 8–9 and handout). (Add local prevalence data, slide 10.) ■ Highlight subgroups that may be at higher risk or particularly relevant to health- care providers (pregnant women, women living with HIV, women with disabilities, indigenous women and women who engage in sex work) (slide 12). Health and socio-economic consequences of VAW (slides 13–15) ■ Highlight the many short- and long-term physical and mental health consequences for women (slide 14) and for their children (slide 15). ■ Describe the social and economic consequences (slide 15). Role of health-care providers (slides 16–21) ■ Providers are often seen as role models in the community and are trusted by women (slide 17). ■ Women subjected to violence may have emotional needs, need for reassurance and ongoing safety concerns in addition to physical health needs (slide 18). ■ The provider’s role focuses on empathic support and care, and referral to other services where available (slide 19). Providers are not responsible for solving the violence or related issues or making decisions for women (slide 20). ■ Ignoring violence can do harm. Thus, it is important to look at the possible consequences of provider behaviours (slide 21). Video (5 minutes) Presentation with slides and discussions (35 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 19 WHO tools and guidelines to assist providers (slides 22–25) ■ Note WHO clinical and policy guidelines as well as clinical guidelines for responding to child and adolescent sexual abuse (slide 23), ■ and two implementation tools – the clinical handbook for health-care providers (slide 24) and the health manager’s manual (slide 25). Slides 24 and 25 on the implementation tools could be left out if time is short, as the content will be covered later. Take-away points (slides 26−27) ■ The health sector and health-care providers have a crucial role to play in identifying and supporting survivors. Note that most topics in this session will be explored more deeply later. Ask if there are points that need clarification now (10 minutes). Distribute handouts for reading after class: Addressing provider barriers to responding to violence against women and Why does the health-care provider response matter? Ask if there are any questions or concerns. State the key messages: ■ Violence affects women’s physical and mental health. ■ Health-care providers have an important role to play in providing support and care to survivors. ■ As health-care providers, we may have fears about addressing violence experienced by women who seek health services, but many of us are deeply committed to improving the health and well-being of women who seek care. ■ This training is designed to build knowledge, skills and confidence to respond effectively to survivors of violence. Wrap-up CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 20 Session 2. Understanding the survivor’s experience and how providers’ values and beliefs affect the care they give Preparation and general information Objective 2: Demonstrate behaviours and understand values contributing to safe and supportive service cultures. Competencies ■ Demonstrate self-awareness of one’s beliefs, assumptions, potential biases and emotional responses that can affect interactions with survivors of violence against women. ■ Understand the circumstances and the barriers that women experiencing violence face when seeking support. ■ Recognize the importance of having empathy with survivors. 80–140 minutes Exercise 2.1: to explore providers’ values and beliefs ■ Option A: Myth or Fact? (15 minutes) ■ Option B: Voting with Your Feet (30 minutes) Exercise 2.2: to understand survivors’ experience ■ Option A: Blanketed by Blame (45 minutes) ■ Option B: In Her Shoes (75 minutes) If 60 minutes available for the exercises, you can conduct Exercise 2.1 Option A + Exercise 2.2 Option A If 90 minutes available for the exercises, you can conduct Exercise 2.1 Option A + Exercise 2.1 Option B + Exercise 2.2 Option A or Exercise 2.1 Option A + Exercise 2.2 Option B If 120 minutes available for the exercises, you can conduct Exercise 2.1 Option A + Exercise 2.1 Option B + Exercise 2.2 Option B Guided discussion (20 minutes) ■ Why women do not leave (10 minutes) ■ Barriers to care-seeking (10 minutes) Learning objectives and competencies Session length Training techniques CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 21 Session content Exercise 2.1, Option A – Myth or Fact? ■ Facilitator resource Exercise 2.1, Option B – Voting with Your Feet ■ Facilitator resource ■ Two signs – one that says “agree” and another that says “disagree” Exercise 2.2, Option A – Blanketed by Blame ■ 11 shawls or newspaper sheets ■ 12 character cards Exercise 2.2, Option B – In Her Shoes (requires advance preparation) ■ Facilitator instructions – also see material at: http://raisingvoices.org/innovation/creating-methodologies/in-her-shoes/ ■ 15 stations (A3 or A4 paper or coloured index cards with a destination or character written on each) ■ Participant handout – story cards for each group ■ Why don’t women leave? ■ Barriers to seeking care Introduce the session by explaining that responding to violence against women requires understanding how, as providers, our values, beliefs and attitudes may affect how we provide care as well as our ability to empathize with survivors’ experiences of seeking help. These beliefs and values are often shaped by the same societal norms that lead to stigmatizing women subjected to violence. The activities in this session help participants to critically reflect on these beliefs and values and the underlying norms that shape them by recognizing common myths and beliefs about violence against women, understanding survivors’ experience of seeking help, and clarifying the way our beliefs can/may affect the care we give. Learning objective for the exercise ■ Critically reflect on our perceptions and beliefs that affect the care we provide to survivors. Instructions for facilitators (slide 3) ■ Explain that you would like to spend some time exploring some common myths about violence. Facilitator materials Handouts Background Exercise 2.1, Option A: Myth or Fact? (15 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 22 ■ Ask the participants to share any local beliefs they have heard related to violence against women. ■ Read the first statement of the facilitator’s resource, “Myth or Fact?” to the group. ■ Ask the group whether they think this is a fact or a myth. See if there is agreement within the group or not. ■ Ask one person who believes it is a fact and one who believes it to be a myth to explain the reason for their response. ■ Provide the answer. Note that the statement is a myth or a fact and give the reason. ■ Repeat this for another three statements. (Select statements that seem most relevant to the group.) Spend no more than 3 minutes on each statement. For Guiding questions for discussion and Take-away points, see the sections below under Exercise 2.1, Option B: Voting with Your Feet. Learning objective for the exercise ■ Reflect critically on our perceptions and beliefs that affect the care we provide to survivors. Instructions for facilitators (slide 4) ■ Find a space where participants can easily move around. ■ If the group is too big, split into two or three groups and conduct the exercise in 2–3 different spaces (for example, a breakaway room or different ends of the room). ■ Ask the participants in each group to stand in the middle of the room in a straight line. ■ Place a sign (either on flip charts or pieces of paper in large font) with “Agree” written on one side of the space and on the opposite side a sign with “Disagree” on it. ■ Read out loud one of the statements listed in the facilitator resource. ■ Ask participants to respond by moving towards one of the signs – either agree or disagree – depending on whether they agree or disagree with the statement. ■ Ask the participants to choose how close to the sign they stand based on how strongly they agree or disagree with the statement. ■ After each statement facilitate a discussion about why people chose the places they took. This will help them to dig deeper into their underlying belief systems. ■ Ask each side to explain its point of view to the other side. Allow some time for debate. ■ After a short debate, ask if anyone would like to change position. ■ Repeat this by reading 4–5 more statements, depending on how much time is available. Exercise 2.1, Option B: Voting with Your Feet (30 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 23 Note: This exercise can be intensely personal and uncomfortable for some participants. If you hear discomfort expressed, intersperse the statements on violence against women with those that are under the miscellaneous category to create a nonthreatening atmosphere. This exercise can also result in some participants feeling isolated if their values do not align with those of other group members, or it can create feelings of negativity towards their peers. Encourage participants to maintain a non-judgemental attitude towards beliefs that are not aligned with theirs or with those of the majority of the participants. These are complicated, emotional issues, and some participants may react strongly to the statement and others’ views. Remind them that everyone brings his or her own personal perspective to this exercise and that they need to be respectful of each other. Guiding questions for discussion, Exercise 2.1 (Option A or B) ■ After the exercise is complete, facilitate a group discussion using the following questions as a starting point: ■ How did it feel to confront values that you do not share? ■ What did you learn from this experience? ■ Did you change your opinion about any of the issues? ■ Encourage debate within the group and be ready to spend some time discussing the issues that arise. Take-away points (slide 5) The purpose of this exercise is to reflect on how our personal beliefs about violence against women and values might affect the care that we as health-care providers offer to survivors. ■ Our beliefs and attitudes often reflect the norms and values of the societies we live in. It is important to reflect on these norms and whether they might harm survivors. We must challenge them in our interactions with survivors and as role models to our patients and communities. ■ Women subjected to violence are often acutely aware and can sense when people have negative beliefs and opinions about them. If we are aware of our negative beliefs, we can better avoid communicating them to survivors of violence. ■ Changing mindsets takes time. However, it is possible to change our beliefs and attitudes, and it is healthy to examine and adjust them if necessary. Learning objectives for the exercise (slide 6) ■ Increase awareness of and empathy for the difficulties that women who experience violence face when seeking support. ■ Highlight how unequal gender norms and behaviours can affect women’s ability to seek help and access care. ■ Encourage participants to think about what they can do as providers to offer an empathic response to survivors of violence. Guiding questions for discussion for Exercise 2.1, Option A or B Take-away points for Exercise 2.1, Option A or B Exercise 2.2, Option A: Blanketed by Blame (45 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 24 Instructions for facilitators (slide 7) ■ Have ready 11 shawls or newspaper sheets. ■ Ask 12 individuals to participate in the activity. Invite the others to observe. ■ Ask for one volunteer to play the role of Maya (change name according to country), a woman who has experienced violence. Ask the other 11 to play the other characters written on the character cards. ■ Provide each of the 12 participants with a character card (Handout: Blanketed by Blame). ■ Instruct Maya to sit in the middle. She sits in a chair in front of and facing the other participants. ■ Instruct the other participants to stand around Maya in a circle, facing outwards (away from Maya). Each holds a shawl or newspaper sheet. ■ As facilitator, stand outside the circle and read the script of Maya’s story (Handout: Blanketed by Blame). Then, in the order of characters listed below, explain who Maya approaches for help. ■ Ask each character to read the statement on the character card and then step forward and place a shawl/newspaper over Maya. ■ Order of blanketing (covering Maya with shawl or newspaper): friend, HER mother, neighbour, HIS mother, community health worker (female), priest (male), daughter, police, social worker, lawyer, doctor ■ After all 11 characters have placed a shawl/newspaper on Maya, ask Maya why did she not just leave her partner. Wait for her response. ■ Next, ask each character to reverse this process by reading the statement on the reverse side of the character card and then remove one shawl/newspaper from Maya. This time the characters should face inwards, towards Maya. ■ Order of removing the blanket (the shawl or newspaper): doctor, lawyer, social worker, police, daughter, priest, community health worker, HIS mother, neighbour, HER mother, friend. ■ Participants have 30 minutes for this exercise. After that, the facilitator should guide a 15-minute discussion in plenary. Guiding questions for discussion (record responses on a flip chart and come back to them later in the training) Ask: ■ How did Maya feel? ■ How did each of the other characters feel? (Ask for volunteers.) ■ How did the observers feel? (Ask for volunteers.) Discuss: ■ How did you feel about the survivor’s options for help and about the choices she was able to make? CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 25 ■ Probe: Was she always free or did she have the power to make the decision and seek help? ■ How did the people that Maya approached respond to her? ■ Probe: How could they have done this better? Take-away points: See messages after the instructions for In Her Shoes, below. Learning objectives for the exercise (slide 8) ■ Increase awareness of and empathy for the difficulties that women who experience violence face when seeking support. ■ Highlight how unequal gender norms and behaviours can affect women’s ability to seek help and obtain care. ■ Encourage participants to think about what they can do as providers to offer an empathic response to survivors of violence. Instructions for facilitators (slide 9) ■ Prepare the 15 “stations”. Write the following words, each on one piece of paper: Religion, Friends & neighbours, Violence strikes, Police, Medical care, Family, NGO, Work, Return home, Chance, Cultural leader, Traditional healer, Carry on, Education, and Camp. (There may be other points of contact in your setting that you can add.) Hang these papers up around the room. Spread them out to facilitate movement of the participants. If possible, add some elements to make the stations more realistic – for example, pencils and notepad at Education. Lay down each story card of the different stories at the relevant station, ensuring that the different stories are next to each other and the same stories are layered, with the lowest number on top. (For example, one stack at the station “Violence strikes” with: Zola violence strikes 1, and below that, Zola violence strikes 2, etc. Next to that: Betty violence strikes 1, below that Betty violence strikes 2, etc.) ■ Explain: This exercise will give us the chance to walk in the shoes of a woman who has experienced violence. We will make the kind of decisions that she faces and discuss those decisions. ■ Break the group into small groups of 3–5 participants each. ■ Explain that this is a guided experience, and each group will make decisions through discussion and consensus. ■ Hand each group an identity card of a different character. If there are more groups than identity cards, be sure to have enough copies of identity cards to cover all the groups. Stagger the starts of the groups with the same identity by 5 minutes to avoid many groups being at the same station at the same time. (See character cards and situation cards for “In Her Shoes”). ■ Ask participants in each group to follow the instructions at the bottom of the cards. At each station participants will find a card that is relevant to their character. Ask the participants to read that card and make decisions on the basis of the card. Exercise 2.2, Option B: In Her Shoes (75 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 26 ■ Participants have 45 minutes for this exercise. After that the facilitator should guide a 30-minute discussion in plenary. Guiding questions for discussion (record inputs on a flip chart and refer to the responses later as needed) Ask: ■ How did it feel to walk through the story of this woman? Were you able to put yourselves “in her shoes”? ■ How do you feel about the woman’s options for help and about the choices she was able to make? ■ Probe: Was she always free or did she have the power to make the decision and seek help? ■ How did the people that she approached respond to the survivor? ■ Probe: How could they have done this better? Take-away points for this exercise (slides 10–11) ■ This exercise illustrates the challenging decisions that women face in handling violence and how people respond to them. ■ Women make important safety decisions all the time, and they are the experts on their own situations. Often, however, they have few, if any, options for seeking help and support. Many factors may prevent a woman from obtaining help, including economic barriers, social stigma, legal obstacles and threats of physical violence. ■ When violence against women is considered normal, survivors often feel that they must simply accept it. Many survivors are not believed or are dismissed. Hence, they may feel compelled to stay in violent situations. These situations result from unequal gender norms in our communities. ■ Violence against women is never justified. It does not matter whether or not a woman is married, what she wears, how she acts, what her religion is, or any other factor. It is important to NEVER place any kind of blame on the woman. ■ Health-care providers can help survivors in several ways on the path to healing. They can: ■ reach out to women who they suspect are experiencing violence and ask them about it ■ listen to survivors’ stories ■ show empathy, which can make a big difference to how a woman feels ■ believe women’s experiences and not blame them for the violence ■ ask them about their needs and concerns, and encourage them to look for options ■ support them to make decisions that are right for them, and respect the survivors’ wishes and choices. We will come back to these themes throughout the training. Take-away points for Exercise 2.2, Option A or B CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 27 End this exercise by bringing emotional closure: Ask participants to write in their notebooks one hopeful thing that they learned from this exercise. Transition to a guided discussion on understanding women’s readiness for change and barriers they may face when seeking care. Explain that we want to build on the exercise to understand women’s situations and explore two questions: Question 1: When we hear about women’s experience of violence, we may wonder, “Why doesn’t she just leave her partner?” Lead a discussion. ■ Open the discussion by asking for reasons why someone might not leave a job they hated but had worked at for a long time and had a good salary. ■ Ask participants if they have wondered why women do not leave violent situations. If so, what are their reflections about why they do not leave? Draw on the participant handout “Why don’t women leave?” ■ Probe for individual, social, cultural, economic and institutional barriers. ■ Are there any other reasons not listed here? ■ What might be some of the most important barriers in our specific setting? Key points for discussion: ■ Making change is a process. Women are not always ready to take action for a variety of reasons, and they may never be ready. Yet providers must always be ready to respond, so that, when she is ready, she has the support she needs. Even moving a woman along the path towards readiness to seek care or to adopt safety strategies is a valuable contribution. ■ Health-care providers can be helpful in addressing women’s fears and sense of isolation and in setting norms that make it clear that abuse is not part of healthy relationships. Question 2: We may also ask, “Why do women who experience violence delay seeking care?” Lead a discussion on what barriers either prevent or cause delays in survivors seeking care for symptoms linked to violence. Draw on the handout “Barriers in seeking care”. ■ Probe for individual, social, cultural, economic and institutional barriers. ■ Are there any other reasons not listed here? ■ What might be some of the most important barriers in our specific setting? ■ Are there any other reasons why women might not seek help? ■ How can we support women to obtain the help they need? Key points for discussion: ■ Some of the same reasons that women have for not leaving their relationships can also inhibit care-seeking. Guided discussion (20 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 28 ■ The WHO Multi-Country Study found that most women who had experienced violence by an intimate partner had not told anyone about their partner’s violence (when they did it was mostly friends and family). They had not sought help from a service provider or agency either; when they did it was mostly health services. ■ Some of the most common reasons for seeking help (social services) reflect “turning point” moments, including the following: ■ She could not endure any more. ■ She was badly injured or feared for her (or her children’s) life. ■ Her partner had threatened or hit her children. ■ She had been encouraged by friends or family. ■ While we naturally want to prevent further abuse, it is essential that women themselves remain in control of the process to determine when and how they want to create change. Being aware of the barriers helps providers counter them – for example, assuring women that they are not to blame, and helping them understand how serious violence can be and how it impacts their health. ■ Acknowledge that achieving safety is a long-term goal for women subjected to violence and that safety differs for each person. ■ Distribute the handouts Why don’t women leave? and Barriers to seeking care. Ask if there are any questions or concerns. State the key messages (slide 12): ■ The exercises in this session illustrate the challenging situations, decisions and responses that women subjected to violence face. By putting ourselves in the shoes of the survivor, we can empathize and better understand their situations. ■ As providers, it is important to reflect on our own values and beliefs that are shaped by society and how we may convey these to our patients − by stigmatizing them and causing them additional trauma. It is important NEVER to place any kind of blame on the woman. We can also remind others not to blame victims for the violence they experience. ■ Given the barriers to leaving relationships or even sharing abuse experiences, it is important to remember that safety is a long-term goal. ■ As providers, we always encourage women to look for options in their lives and support them to choose what they believe is right for them. Wrap-up CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 29 Session 3. Guiding principles and overview of the health response to violence against women Preparation and general information Objective 2: Demonstrate behaviours and understand values contributing to safe and supportive service cultures. Competencies ■ Know the guiding principles of providing women-centred care in a culturally appropriate way. ■ Understand how to apply the guiding principles for women-centred care in your practice. 30 minutes ■ Presentation with slides (30 minutes) ■ Poster or small pocket card summarizing LIVES (first-line support) ■ Clinical handbook, pages 3–5 Introduce the session by explaining that the WHO clinical handbook, which is largely the basis for this training, was developed with woman-centred care as the basis of an appropriate and supportive response to violence against women. In this session we will better understand and learn how to apply these principles in clinical practice. We also will begin to become familiar with the overall structure and content of the clinical handbook. Learning objectives and competencies Session length Training techniques Handout Accompanying reading Background Session content CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 30 Slides for Session 3 cover the following content (for details, see the slide notes in the PowerPoint file): Guiding principles (slides 3−8) ■ The two fundamental principles for woman-centred care are respect for human rights and promotion of gender equality (slides 4–6). ■ Privacy, safety and confidentiality are essential for providing care to women subjected to violence (slide 7). ■ There are additional considerations for children and adolescents who have been sexually abused (slide 8). These are based on the principles of best interest of the child and evolving capacities. Contents of clinical handbook (slides 9−10) ■ The rest of this session presents an overview of the clinical handbook. Clinical handbook part 1: Identifying women subjected to violence (slides 11−13) ■ Discuss entry points for health care for women subjected to violence in their settings (slide 12). ■ Contrast universal screening and clinical inquiry. WHO does not recommend universal screening for intimate partner violence but instead recommends clinical inquiry (slide 13). Clinical handbook part 2: First-line support (slides 14−16) LIVES job aid ■ The word “LIVES” can help you remember the elements of first-line support (slide 15). This training will build skills for the elements in “LIVES”. (This concept is adapted from psychological first aid.) ■ If you have only one hour to train health-care providers, first-line support – LIVES – is what you want to pass on. Refer them to the LIVES job aid (either page 14 of the clinical handbook, the card on the last page of the clinical handbook or the LIVES poster). ■ Show the summary protocol on care for survivors of intimate partner violence (slide 16). Clinical handbook part 3: Clinical care for sexual assault/abuse (slides 17−18) ■ Show the summary protocol on how to care for survivors of sexual assault/abuse (slide 18). ■ The training will follow the steps outlined in the summary protocols. Clinical handbook part 4: Mental health care (slides 19−20) ■ Even if not trained as a mental health specialist, you can offer basic psychosocial support, assess mental health status for moderate to severe depression, suicidality or post-traumatic stress disorder (PTSD) and refer to a specialist if needed. The training will cover these basic steps (slide 20). Presentation with slides and guided discussion (30 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 31 Clinical handbook addendums: Considerations for family planning and HIV settings (slides 21–22) ■ Women seeking family planning or HIV testing services may experience violence as an underlying situation and face specific challenges to the uptake of contraceptives or disclosing HIV status. ■ Providers in these settings not only need training in identification of violence and first-line support; they also need to know how to offer counselling for family planning and HIV disclosure while keeping in mind women’s need for safety. Two responsibilities of managers: reporting violence and enabling health systems (slides 23–25) ■ Reporting considerations (slide 24): WHO does not recommend mandatory reporting for women subjected to violence. ■ Enabling health systems (slide 25): This training does not go into aspects of management, but participants with managerial responsibilities can refer to the health manager’s manual for strengthening systems for guidance. Ask if there are any questions or concerns. State the key messages (slide 26): ■ The health system response should be based on respect for human rights and promotion of gender equality. ■ This training will cover and seek to build skills in the five parts of the WHO clinical handbook. ■ An enabling health system is key to helping providers put training into practice. Wrap-up CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 32 Session 4. Provider–survivor communication skills Preparation and general information Session content Objective 2: Demonstrate behaviours and understand values contributing to safe and supportive service cultures. Competency ■ Communicate empathically and effectively with patients/survivors. 45 minutes ■ Discussion and presentation (15 minutes) ■ Exercise 4.1: Active listening (30 minutes) ■ Active listening principles ■ Clinical handbook, pages 42–45, section titled “Communicate”; page 89, “Tips for talking with clients” Introduce the session by noting that Listening is the first element of LIVES. Listening is something we do all the time, but we do not always listen mindfully or consciously. Good listening skills can be practised. Good listening makes a big difference to what women subjected to violence will disclose, how supported they feel and how quickly they can begin healing. We will use this session to reflect on and practise the art of listening and elements of good listening skills. Learning objectives and competencies Session length Training techniques Handouts Accompanying reading Background CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 33 ■ Discussion: How do we know if someone is listening to us? Slides for Session 4 cover the following content (for details, see the slide notes in the PowerPoint file): Review principles of active listening ■ Distribute handout Active listening principles and discuss active listening practices (slide 3). ■ Review and demonstrate the principles of good listening posture (the mnemonic SOLER) (slide 4). Learning objective for the exercise ■ Appreciate and practise active listening. Instructions for facilitators (slide 5) ■ Ask participants to form pairs with another participant. ■ Ask participants to recall a challenging situation in any area of life and to tell their partner a story about it for about 5 minutes. NOTE: Do not use an example related to violence, as this time is too short for dealing with a disclosure of violence. ■ Ask the listener to practise active listening, including open-ended questions, non-verbal communication and non-judgemental responses. Refer them to the handout Active listening principles for reminders of active listening practices. ■ After 5 minutes, ask the participants to switch roles so that the person who first listened now tells his or her story for about 5 minutes and the other partner becomes the active listener. Guided discussion (slide 6) In plenary, ask the participants the following questions: ■ What did your partner do to show she/he was listening attentively to you? ■ What did your partner say that showed active listening? ■ What did your partner NOT do or say – both good and bad? ■ How did you feel afterwards? Ask participants which communication skills are most useful to their clinical settings and appropriate in their contexts. Discussion and presentation (15 minutes) Exercise 4.1: Active listening (30 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 34 Ask if there are any questions or concerns. State the key messages (slide 7): ■ Survivors of violence are often silenced by abusers, family members, others in the community – and even health-care providers. By contrast, active and supportive listening allows survivors to feel heard – an important step towards healing and enabling disclosure of violence. ■ Empathic and effective communication takes place throughout the meeting. ■ Use both verbal and non-verbal skills. ■ Start by asking open-ended questions. Wrap-up CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 35 Session 5. When and how to identify intimate partner violence Preparation and general information Objective 3: Demonstrate clinical skills appropriate to one’s profession and specialty to respond to violence against women. Competencies ■ Understand the minimum standards that need to be met to enquire about and respond appropriately to violence against women. ■ Recognize the signs and symptoms that suggest intimate partner violence. ■ Understand when and how to ask about intimate partner violence. ■ Demonstrate appropriate ways to ask about intimate partner violence. 40 or 70 minutes ■ Presentation with slides (10 minutes) ■ Exercise 5.1, Option A: Role play on identification of intimate partner violence (60 minutes) OR (depending on amount of time available) ■ Exercise 5.1, Option B: Case reviews on identification of intimate partner violence (30 minutes) ■ Asking about violence ■ Role play on identification of intimate partner violence (Exercise 5.1, Option A) ■ Case reviews on identification of intimate partner violence (Exercise 5.1, Option B) ■ Clinical handbook, pages 8–11 Learning objectives and competencies Session length Training techniques Handout Facilitator materials Accompanying reading CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 36 Remind participants that health-care providers are in a unique position to help survivors of intimate partner violence. Survivors can often seek health care without coming in specifically to discuss violence. Health-care providers tend to be the first point of professional contact for survivors. As a health-care provider, you may suspect violence and identify survivors (refer to page 8 of the clinical handbook). Slides for Session 5 cover the following content (for details, see the slide notes in the PowerPoint file): ■ Minimum requirements need to be in place before asking about violence. These are protocols, training, privacy, confidentiality and a referral system (slide 4). ■ Privacy: Never discuss violence if anyone else – even a friend – is present or may be able to overhear. You may need to think of a strategy to be able to see the woman alone, such as sending the person to do an errand or to fill out a form. ■ Reminder: WHO recommends clinical inquiry. Universal screening is not recommended (slide 5). (Refer to page 17 of the WHO clinical and policy guidelines for more information.) ■ Women subjected to intimate partner violence often seek health care for related emotional or physical conditions. (When to suspect that a woman is experiencing violence and make an enquiry is covered in slides 6–7 and in the clinical handbook, page 9.) ■ When asking about violence, raise the topic indirectly first (slide 8), then more directly if appropriate (slide 9). Sample statements are provided in the job aid on asking about violence on page 11 of the clinical handbook. Other statements can be used, as appropriate, and they do not all need to be used. ■ Often, women will not tell you about violence (slide 10). See also page 12 of the clinical handbook. Emphasize the following: ■ Remember the principles of women-centred care. ■ Your verbal and non-verbal communication skills are important for building trust when and if a woman is ready to disclose abuse and obtain help. ■ She may not disclose to you the first time that you ask – or ever – and you need to respect her decision. Conduct the exercise. See instructions below. ■ Questions that providers may have (slides 16–17), with responses, are covered in pages 34−37 in the handbook and in a living annex on the WHO website. Background Presentation with slides (10 minutes) Session content CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 37 Note to facilitator: Refer to the instructions for role plays in Annex 5 for a reminder on how to provide feedback to role play participants. Learning objective for the exercise (slide 11) ■ Practise appropriate ways in which to raise the topic of violence and to ask about violence. Instructions for facilitators (slide 12) Show a video demonstrating providers asking about violence. If a video is not available, a pair of facilitators can demonstrate the role play. For the role plays: ■ Divide the participants into groups of three. ■ Ask one person in each group to volunteer to play the role of a patient/survivor, another to play the role of a health-care provider, and the third to be the observer who will provide feedback to the other two. ■ Hand out the scenarios (Participant handout – Identification of intimate partner violence). Give the patient scenario to the survivor and the observer but not to the provider. Explain the following: ■ The patients read the scenario. They play the role of the survivor and describe their symptoms or conditions to the health-care provider. They do not share information regarding the violence unless they are asked by the health-care provider and feel comfortable sharing. ■ The health-care providers’ job is to provide care and ask relevant questions. If necessary, they raise the topic of violence and/or ask about violence. ■ The observers’ role is to read the guidance in the clinical handbook (page 11) and provide feedback to the health-care worker on her or his approach to asking the woman about violence. The observer should pay attention to the questions asked as well as the overall verbal and non-verbal communication. Suggestion to facilitator: Walk around the room and ask at least one client NOT to disclose violence (discreetly). This would enable the health-care worker to practise skills in providing support to the patient even if she does not disclose. After 10 minutes of doing the role play or after disclosure of violence if earlier, the observer should stop them and discuss for 5 minutes: ■ How did the participant playing the role of the survivor feel talking to the provider? ■ Ask the observer to provide feedback on how the health-care worker asked questions, how he/she responded to the survivor, and how the non-verbal communication was. ■ Ask the health-care worker to reflect on what other actions could help the woman. Exercise 5.1, Option A: Role play on identification of intimate partner violence (60 minutes) Note: Choose Exercise 5.1, Option A (60 minutes) or 5.1, Option B (30 minutes) depending on the amount of time available. CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 38 If there is time, ask the participants to switch roles and do another role play. After the role play, facilitate a discussion with the whole group to debrief their experiences (30 minutes). The questions below can be used as a guide. ■ For those playing the role of patients, how did you feel about being asked about violence? ■ Probe: Did you disclose abuse? Why or why not? ■ Probe: How did you feel when you disclosed? ■ For those playing the role of health-care providers, how did you feel about asking about violence? ■ Probe: What made you suspicious about the possibility of violence? ■ Probe: Did you hesitate to ask? If so, why? ■ Probe: How did you feel when she disclosed her experience of violence, or if she did not disclose? ■ For those playing the role of observers, how did you feel about what was going on? ■ Probe: How was the verbal and non-verbal communication? How did health- care providers communicate or not communicate support? ■ What did you notice about the woman’s willingness to disclose her experience of violence? Did she hesitate or not? ■ What could the health-care provider have done better in the situation? Learning objectives for the exercise (slide 13) ■ Recognize signs and symptoms that suggest violence. ■ Practise appropriate ways to raise the topic of violence and to ask about violence. Instructions for facilitators (slides 14–15) ■ Ask participants to work in groups of 4–5 and review what is presented in the handout Case reviews on identification of intimate partner violence. ■ The groups will have 10 minutes to read the cases and discuss and agree on answers to the following questions: ■ Do you think this person may have experienced violence? What makes you think this? ■ How would you raise the topic? What are the questions you would ask? Please write them down. ■ After the participants have reviewed the cases, discuss them in plenary using the exercise below. Plenary exercise ■ As facilitator, take the role of the survivor in the cases provided. All participants take the role of the provider. (If there are several facilitators, this exercise is best done in small groups.) Exercise 5.1, Option B: Case reviews on identification of intimate partner violence (30 minutes) Note: Choose Exercise 5.1, Option A (60 minutes) or 5.1, Option B (30 minutes) depending on the amount of time available. CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 39 ■ State, as the patient, why you are there and ask all participants (the providers) to ask questions. The group work they did will help them in this exercise. ■ Encourage all participants to ask questions and actively participate. ■ In the role of the patient, answer each question that the “providers” ask. ■ After each of the cases, ask the participants which questions worked well, and which did not. Note the type of questions that worked well (for example, open- ended, indirect to start). ■ If the questions are not sensitive, address this. ■ If the questions are not leading anywhere, address this. ■ If participants ask closed questions, only respond with “yes” or “no”, not giving any further information. ■ Ask and discuss: What approaches worked well? After you discuss all three cases, point out that different approaches may be necessary for each survivor depending on the responses and circumstances. It is important to take a survivor-centred approach – ensuring that you listen well to what the survivor tells you – to hear her needs and ask about them without blaming her. In examining her, keep in mind the fears discussed in the first session. Ask if there are any questions or concerns. State the key messages (slide 18): ■ Partner violence is identified by staying attentive to possible clinical cues. ■ First, ask general questions about relationships, the situation at home, etc. ■ Ask about violence compassionately, without judgement. ■ Many survivors will not disclose. Even so, providers have an important role – providing information and building trust. ■ Verbal and non-verbal communication skills are important. ■ Active and empathic listening provides important support. ■ Skills to identify/ask improve with practice. Wrap-up CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 40 Session 6. First-line support using LIVES, part 1: Listen, Inquire, Validate Preparation and general information Objective 3: Demonstrate clinical skills appropriate to one’s profession and specialty to respond to violence against women. Competencies ■ Know the content of first-line support (LIVES). ■ Demonstrate skills in offering the first three elements (listening, inquiring and validating) of first-line support to survivors who disclose abuse. 105 minutes ■ Presentation with slides (15 minutes) ■ Video demonstrating identification of violence and LIV elements of LIVES, followed by guided discussion (https://youtu.be/Hu06nVCzih0, minutes 8:40 to 14:20 and 14:47 to 20:36) (30 minutes) ■ Exercise 6.1: Role play to practise LIV(ES), part 1 (60 minutes) ■ Communication skills and pathways ■ Health-care providers’ common questions (pages 34–37 of the clinical handbook) ■ Exercise 6.1: Role play scenarios on LIV(ES), part 1 ■ Clinical handbook, pages 13–24 Learning objectives and competencies Session length Training techniques Handouts Facilitator materials Accompanying reading CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 41 Slides for Session 6 cover the following content (for details, see the slide notes in the PowerPoint file): What is first-line support? ■ First-line support is the most important care that you can provide (slide 3). ■ “LIVES” is first-line support for violence against women (slide 4). This session covers the first part – LIV – of first-line support. The second part – ES – is covered in Session 8. ■ Listening is more than just hearing a woman’s words. It is the most important part of good communication and the basis of first-line support. It gives the woman a chance to say what she wants to a caring person who wants to help. This should be done in a safe and private place (slide 5–6). ■ Inquiring about her needs and concerns in a caring way, putting her at the centre of decisions (slide 7). ■ Validating what she is telling you. Showing that you understand what she is saying and that you believe what she says without judgement or conditions (slide 8). ■ Distribute handout Communication skills and pathways. Introduce the video (slide 9) by encouraging participants to look for the communication skills and pathways highlighted on the handout and in the specific steps of LIV. Prompt them to think how they might communicate the same points in their own words. Show video modelling good practice for identification of violence and the LIV elements of LIVES (15 minutes). The video is at https://youtu.be/Hu06nVCzih0 (link to video on slide 9). Show the video from 8:40 to 14:20, then from 14:47 to 20:36. (This video is from the Royal Australian College of General Practitioners Professional Development Program on Family Violence, https://www.racgp.org.au/familyviolence/ modules.htm.) Guided discussion of video (15 minutes) Ask participants to reflect on each of the LIV elements: ■ How did the provider demonstrate listening? ■ What non-verbal cues were used? ■ What else could be done? ■ How did the provider demonstrate inquiring? ■ What types of questions were used? ■ How else could this be done? Presentation with slides (15 minutes) Video and guided discussion (30 minutes) Session content CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 42 ■ How did the provider demonstrate validating? ■ How else could you respond? Note to facilitator: Refer to the annex on providing feedback to role play participants. Learning objective for the exercise ■ Develop skills for the LIV elements of first-line support. Instructions for facilitators (slide 10) ■ Divide participants into groups of three. Ask each group to decide who will play the role of a patient, a health-care provider and an observer. ■ Hand out the instructions and the scenarios only to the patients and observers and ask them to read and prepare. ■ Ask the patients and the observers to read the instructions and the scenarios and to choose a scenario to play out. ■ The role of the patient is to tell the health-care worker why she is there and to respond to questions asked by the health-care provider. ■ Based on the scenario selected, the health-care provider should ask about violence and provide first-line support to the client using what they have learned about LIV(ES). ■ The observer’s role is to observe the verbal and non-verbal communication between the health-care provider and the patient and, at the end of the role play, to provide feedback to the health-care provider on her or his skills in providing the first three elements of first-line support. Tell patients and providers to practise the role play for 10 minutes. Instruct the observer to provide feedback to the health-care worker for 5 minutes. The group should then switch roles within their group and repeat the exercise using the other scenario. Option A: Facilitate a group discussion to debrief each scenario Facilitate a group discussion to debrief their experiences (30 minutes). The questions below can be used as a guide: ■ To those who played the role of the patients: ■ How did you feel about the health-care worker asking about violence? ■ Did you disclose violence? Why or why not? ■ To health-care providers: ■ How did you ask about the patient’s experience of violence? ■ How did you feel if the patient disclosed? ■ What did you say to the patient who disclosed violence? ■ If no disclosure: How did you decide to stop asking about violence? How did you leave the door open for further discussion? Exercise 6.1: Role play to practise LIV(ES), part 1 (60 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 43 ■ To observers: ■ How was the non-verbal communication? ■ How forthcoming was the patient about her experience of violence? Why? Note: Some participants may overplay the scenario or act as rushed or disinterested providers. These scenarios of “missed opportunity” can be highly instructive. In discussion highlight the barriers to discussion of violence (time, disinterest, burnout, lack of privacy may come up). Take this opportunity to acknowledge the challenges that the system can present. Invite reflection on what can be done differently, or how a colleague could be approached for support. Option B: Invite selected participants to role-play each scenario in front of the group Note: Do this only if you are sure these participants will demonstrate quality care and will feel comfortable receiving feedback from the entire group. Thank participants for volunteering; it is brave to do this in front of an audience. Invite feedback from the broader group. ■ Begin with positive feedback: What was done well? ■ What are opportunities for improvement? Distribute handout on Health-care providers’ common questions or refer to pages 34–37 of the clinical handbook. Ask if there are any questions or concerns. State the key messages (slide 11): ■ As we have noted throughout the training, effective listening and LIVES can be a powerful healing tool for survivors. For some, first-line response alone can be what they need to move forward. ■ Remember to minimize distractions and focus on your patient for most effective communication. ■ Take the time to continue practising the LIV portions of LIVES, and think about how you can provide first-line support using your own words. Wrap-up CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 44 Session 7. Know your setting: identify referral networks and understand the legal and policy context Preparation and general information Objective 4: Demonstrate knowledge of how to access resources and support for patients and for oneself. Competencies ■ Understand the role of other services in caring for survivors of violence against women. ■ Know what resources are available in the community. ■ Know the legal and policy context, including health-care providers’ legal obligations, with regards to the local and national response to violence against women. 70 minutes (without additional below) Additional 30 minutes for optional exercise Additional 30 minutes for optional invited guest ■ Presentation with slides and guided discussion (20 minutes) ■ Guided discussion on policy context (20 minutes) ■ Exercise 7.1: The Web of Referrals (30 minutes) ■ Exercise 7.2 (optional): Drawing the ideal referral pathway (if participants have managerial responsibilities) (30 minutes) ■ Optional/encouraged: Invited guest to present on legal/policy context or on referral services available locally (30 minutes) ■ Exercise 7.1: The Web of Referrals – character cards ■ Exercise 7.2: Drawing the ideal referral pathway – template (job aid 8.1 in the health manager’s manual, page 91) ■ Clinical handbook, pages 29–32 (section on social support and job aid referral chart) ■ Health manager’s manual, Annex 6 (sample referral directory form), chapter 3 pages 33–36, chapter 6 page 65 and chapter 8 pages 82–93 Learning objectives and competencies Session length Training techniques Facilitator materials Accompanying reading CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 45 Session content Guest speakers to consider (see section in the introduction on Guest speakers and resource persons) ■ Referral portion: Invite a health-care provider who cares for women subjected to intimate partner or sexual violence or an advocate to discuss the services available, referral pathways and ways to strengthen ties. ■ Policy portion: Invite a Ministry of Health official or other person knowledgeable about national, subnational and institutional policy to present on the local policy environment. Slides for Session 7 cover the following content (for details, see the slide notes in the PowerPoint file): Discuss what needs women may have that the health system cannot meet. Explain that helping women access these services is essential for their health and safety. Establishing referral pathways ■ Indicate the principles for referrals, always respecting and following the survivor’s choice (slide 3). ■ Highlight how to establish referral pathways (slide 4), including identifying and mapping available services, making referral agreements with known resources and making a referral directory (refer to the job aid – slide 5). Discuss what it means to “know a resource” (slide 6). ■ Explain how to provide “warm referrals” (slides 7–8). Warm referrals help reduce barriers. ■ If participants have managerial responsibilities: Highlight the steps of developing referral pathways through the handout of job aid 8.1 from the health systems manual (slides 15–17). See optional exercise 7.2, below. Legal and policy context ■ Describe the legal and policy context or ask someone to describe it (slides 9–11). ■ Specifically, for example, what laws apply to or have implications for health-care providers’ response to sexual violence, intimate partner violence and child sexual abuse? Specifically, what do laws and policies say about abortion services, access to abortion and emergency contraception, age of sexual consent, age of parental consent for adolescents’ access to care, mandatory reporting, who is authorized to perform forensic examinations and testify in court if applicable, and what are the legal and policy obligations or limitations to confidentiality of information and sharing data? Invited guest Presentation with slides and guided discussion (20 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 46 Learning objective for the exercise (slide 12) ■ Appreciate how a lack of coordination and too much specialization can make referrals burdensome for the survivor. Instructions for facilitators (slide 13) ■ Ten volunteers are needed. TIP: If the group is very large, it can be split into two. ■ Ask 9 volunteers to come to the front and form a circle. Ask for a 10th volunteer to stand in the centre to play the role of Rose, a violence survivor. Ask the rest of the participants to be outside the circle and to observe the situation. ■ Give each volunteer in the circle a character card with instructions. TIP: Mix the order of the cards before handing them out. Give Rose the description of her situation (participant handout for Web of Referrals exercise) and a ball of coloured thread or yarn. ■ Read Rose’s story to the group: Rose is a 28-year-old woman who has been experiencing physical and sexual abuse from her boyfriend for the last six months. She does not know what to do, and so she first approaches her sister for help. ■ Ask Rose to play her character and approach her sister. Ask Rose to take the ball of thread with her wherever she goes but to give the end of the string to her sister and unwind the string from the ball as she goes. ■ Ask the sister to respond to Rose as per her card instructs and to take the end of the thread. Thereafter, each character that Rose visits should play their role as instructed on their card. Rose gives the thread to each person she meets. Then she unwinds more thread from the ball as she goes to the next person. By the end of the exercise, Rose has re-told her story to multiple people and is standing in the midst of a tangled web of thread. Group discussion ■ Ask the observers: How often did Rose have to repeat her story? ■ Ask Rose how she felt repeating her story so many times? ■ Ask those who played the other characters: Did you feel that you could be helpful to Rose? ■ Ask the whole group: ■ Is this situation realistic? Is this what happens in your setting? ■ What could have been done to avoid this web of string? ■ What could be done to minimize the need for Rose to repeat her story? Exercise 7.1: The Web of Referrals (30 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 47 Learning objective for the exercise (slide 14) ■ Think through how to draw a referral pathway for your locality. Instructions for facilitator (slide 14) Give each participant a template for developing an ideal referral pathway. (Participants from the same facility or region can work together.) Ask the participants to draw out a referral pathway for their health facility/region. Designate whether the pathway is for sexual assault or intimate partner violence. The pathway should include connections both within and between facilities, and the information flow among these in both directions. In developing the ideal referral pathway, participants should use, as a model, job aid 8.1 in the health manager’s manual, page 91 (also available as a handout), especially Step 5, page 93, and follow these instructions: ■ To draw the ideal referral pathway, think what it means to put the woman’s needs at the centre, protecting her privacy and confidentiality and minimizing the need for her to repeat her story. ■ Identify and write down the formal supports for which she may need referrals (for example, police, health-care provider, social worker, legal services), as well as the informal supports that may be useful (for example, family and friends, social networks, village elders, religious and traditional leaders). ■ Specify sequences or paths that the survivor could follow, taking into account her wishes and preferences. Group discussion After the exercise reconvene all the participants. Ask the groups (or individuals) to present their referral pathways. Facilitate discussion of the following themes: ■ Referrals in accordance with her wishes and needs (self-determination principle) ■ Confidentiality and safety in referral process ■ Identifying and overcoming barriers to referrals (for example, transportation) ■ The provider’s role is to connect women with care – not to provide all aspects of necessary support (for example, legal aid). This discussion may identify new resources, which can be shared with the group. Introduce guest speaker to present on either the legal and policy context or on available referral resources in the community. ■ Facilitate discussion depending on the speaker’s focus. Exercise 7.2 (optional): Drawing the ideal referral pathway (for health managers or providers with managerial roles) (30 minutes) Invited guest CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 48 Ask if there are questions or concerns. State the key messages (slide 18): ■ Active and up-to-date referral networks and warm referral practices can help women more easily access the care that is available. ■ Make referral agreements with known resources. ■ Remember, self-determination is at the core of the referral process. ■ Providers are responsible for knowing the legal and policy context that affects the care they provide. Wrap-up CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 49 Session 8. First-line support using (LIV)ES, part 2: Enhancing safety and providing Support Preparation and general information Objective 4: Demonstrate knowledge of how to access resources and support for patients and for oneself. Competencies ■ Demonstrate the skills to assess immediate risk/safety and to support safety planning. ■ Know what resources are available in the community. ■ Know how to collaborate with partners to help survivors access other services and to provide referrals. ■ Demonstrate skills to provide warm referrals. 95 minutes ■ Presentation with slides (5 minutes) ■ Demonstration role play with discussion (30 minutes) ■ Exercise 8.1: Role play to practise (LIV)ES, part 2 (60 minutes) ■ Exercise 8.1: Role play scenarios on (LIV)ES, part 2 ■ Clinical handbook, pages 25–33 Learning objectives and competencies Session length Training techniques Facilitator materials Accompanying reading CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 50 Introduce the session by reminding participants that in Session 6 they learned skills for the first three elements of LIVES (Listen, Inquire, Validate). In Session 7, participants learned how to establish survivor-centred referrals, identify resources in the community and maintain a referral directory. This session will cover skills and practice for the last two elements of LIVES (Enhancing safety and providing Support). Empathic, active communication throughout will make the conversation more effective and comfortable for both you and your client. The slides for Session 8 cover the following content: (for detail, see the slide notes in the PowerPoint file): Enhancing safety ■ When assessing safety after sexual assault or partner violence, discuss whether or not it is safe for the woman to go home (slide 4). Partner violence is not likely to stop on its own. Safety concerns should be taken seriously, and women should be helped with safety assessment and plans. ■ Review the risk assessment job aid in the clinical handbook on page 26 and the safety planning job aid on page 27 (slide 5). ■ If the woman is not safe, help her to make a safety plan and make the necessary referrals (slide 6). ■ Safety is a long-term goal. A woman may not be ready to take action now, but she needs to know what to do. ■ To avoid putting her at risk, be sure to maintain privacy and confidentiality (slide 7). Facilitating social support (slide 8) ■ Discuss with her what is most important to her, and help her identify and consider her options. ■ Providers should use and update the referral directory job aid as the basis for facilitating access to formal social support based on her needs. Also, or instead, women may prefer to rely on their informal networks. ■ Health-care providers play an important role by connecting women to needed resources and, through warm referrals, encouraging them to seek support. Demonstrate a role play with your co-facilitator to show how to assess and support the safety of a survivor and to facilitate social support (the E and S elements of LIVES). Use one of the scenarios in the LIVES role play handout (10 minutes). Ask participants to reflect on each element of the ES phase, and lead a discussion on the following questions (20 minutes): ■ How did the provider raise the topic of safety? ■ How did the provider show respect for the woman’s decisions? Background Presentation with slides (5 minutes) Demonstration role play (30 minutes) Session content CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 51 ■ How did the provider facilitate access to social support – informal and formal? ■ How else could this be handled? What would you do differently? Similarly? Note to facilitator: Refer to the annex on providing feedback to role play participants. Learning objective for the exercise (slide 9) ■ Practise skills in how to assess and help with safety and to link or connect a woman to both informal and formal social support. Instructions for facilitators (slide 10) ■ Divide participants into groups of three. Ask each group to decide who will play the roles of a patient, a health-care provider and an observer. ■ Hand out the instructions and the scenarios only to the patients and observers and ask them to read and prepare. ■ Ask the patients and the observers to read the instructions and the scenarios and to choose a scenario to play out. ■ Ask the patient: Read the scenario but do not initially share the details with the others. When instructed by the facilitator, only read out loud the information in items 1 and 2 to your health-care provider. ■ Ask the health-care provider: Listen to the patient’s disclosure of abuse and provide first-line support with a focus on assessing and facilitating safety and facilitating access to social support (steps E and S from LIVES) as instructed in the clinical handbook, pages 25−33. ■ Ask the observer: Note the verbal and non-verbal communication between health- care provider and patient. Provide feedback at the end of the role play to the provider. Remind observers of the tips for providing feedback on role plays (Annex 5, p. 88). ■ The group should then switch roles within their group and repeat the exercise using the other scenario. ■ Each role play should take about 10 minutes. The observer should take no more than 5 minutes to provide feedback. Guided plenary discussion Ask groups to discuss their role plays. You can use the following questions: ■ To patients: ■ How did you feel about the way the health-care provider responded to your situation and needs? Did you feel that you were listened to? Why or why not? ■ How appropriate to your situation and priorities were the safety tips and recommendations for accessing social support? ■ To health-care providers: ■ How comfortable were you in assessing and helping the patient with safety and facilitating social support? ■ Tell us about what you struggled with in your discussions with her about safety and social support. Exercise 8.1: Role play to practise (LIV)ES, part two, and discussion (60 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 52 ■ To observers: ■ What did the health-care provider do well in their interaction? ■ What could they have done differently or better? Ask if there are any questions or concerns. State the key messages (slide 11): ■ Risk assessment can help understand women’s immediate safety needs. ■ Trust your patient when she tells you she is in severe danger. ■ Providing linkages to support services is a core activity in the response to violence. ■ Always provide referrals that respond to her stated needs. ■ As much as possible, make warm referrals. ■ Empathic, active communication is most effective and comfortable for both of you. Wrap-up CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 53 Session 9. Clinical care for survivors of sexual assault/rape, part 1: history-taking and examination Preparation and general information Objective 3: Demonstrate clinical skills appropriate to one’s profession and specialty to respond to violence against women. Competencies ■ Demonstrate skills to take a clinical history. ■ Know how to conduct an examination of a survivor of sexual assault, including rape and abuse. ■ Know when to collect forensic evidence and how to support or facilitate such evidence collection. 75 minutes ■ Presentation with slides and with e-learning animation and guided discussion (30 minutes) ■ Exercise 9.1: Role play on history-taking (45 minutes) ■ Responding to children and adolescents who have been sexually abused: WHO clinical guidelines (pages 20–22) ■ Preparing to gather the story ■ Special considerations for medico-legal services for child victims ■ Forensic medical examination ■ Medico-legal evidence in sexual violence ■ USB key or download: clinical management of rape – e-learning (http://apps.who. int/iris/bitstream/handle/10665/44190/CMoR_CDDownloadMultilingualVersion. zip?sequence=2&isAllowed=y) ■ Exercise 9.1: Role play on history-taking scenarios ■ Exercise 9.1: History-taking form (Section 3 of the form for documenting history, pages 91–92 of the clinical handbook – description of the incident) Learning objectives and competencies Session length Training techniques Handouts Facilitator materials CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 54 Session content ■ Clinical handbook: Part 3 pages 39–48, Sample history and exam form (pages 89–98) This is the first of two sessions covering quality care for survivors of sexual assault, including rape and abuse. A woman may find it more difficult to disclose rape, sexual assault or abuse if she knows or has trusted the perpetrator (for example, husband, boyfriend, family member, other relative, acquaintance, school teacher) than if it is a stranger. Providers need to be sensitive to this when asking questions. Also, there are specific considerations in dealing with child or adolescent survivors of rape, sexual assault or abuse. A good history and examination are the basis for providing quality clinical care and psychological support, and also for medico-legal evidence, when relevant and needed. Providers should be familiar with national laws and policies on rape/sexual assault or abuse, including laws and policies related to medico-legal evidence. Also, they need to be familiar with any protocols/standard operating procedures. In some settings forensic examinations of survivors of sexual abuse may be carried out only by designated health-care providers (for example, a sexual assault forensic nurse–examiner, forensic doctor, or providers designated to issue medico-legal certificates). Remind participants that the guiding principle for history-taking and examination is to minimize trauma and stress and avoid re-victimizing the survivor. Also, clinical care should be prioritized. The slides for Session 9 cover the following content: (or details, see the slide notes in the PowerPoint file): ■ Pathway and steps in history-taking and examination, and general tips (slides 3–5) ■ Clinical/medical history ■ The emphasis is on taking the history of the assault (slides 6–7) and assessing her emotional state (slide 8). ■ Point out that the clinical/medical history is the most important aspect of care. It guides the examination and what care needs to be offered, as well as collection of forensic evidence. Accompanying reading Background Presentation with slides + e-learning animation (15 minutes) with discussion (15 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 55 ■ Emphasize the importance of talking to the woman, before taking the history, about any obligation you have to report to the police (slide 9) and the limits of confidentiality. ■ Show e-learning clip on clinical management of rape, demonstrating history- taking (slide 10). Click on step 3, history-taking case study. ■ Examination ■ It is important to communicate and to ask for consent with each step of the examination (slides 11–12). ■ The primary purpose of examination is to provide clinical care and psychological support. At the same time, providers should know when forensic evidence should be collected and some general principles of forensic examination (slides 13–14). Note: Additional details for forensic examination are covered in Session 9a (supplemental session). Discussion: Ask participants if they have any questions and respond to them. Distribute the handouts and refer participants to the additional reading. Learning objectives for the exercise (slide 15) ■ Practise skills in how to take a history with a focus on asking about the sexual assault incident in a sensitive way. ■ Document the history on a structured form. Instructions for facilitators (slide 15) ■ Divide participants into groups of three. Ask each group to decide who will play the roles of the patient, the patient’s mother and the health-care provider. ■ Separate the three character descriptions on the handout and give one description to each participant according to their roles. ■ Ask the “providers” to listen to the patient’s account and then ask about the history of the sexual assault (clinical handbook pages 40–43), record findings on section 3 of the form on pages 91–92 of the clinical handbook (handout), then prepare the survivor for an examination (clinical handbook, pages 43–45). ■ Each role play should take about 10 minutes. Then ask the participants to switch roles within their group and repeat the role play one or two more times. Guided plenary discussion ■ Ask the patients how they felt telling their stories and about the health-care provider’s response. ■ Ask the health-care providers what difficulties they experienced in the history-taking. ■ Ask the entire group for suggestions about how the provider could best deal with the mother. Exercise 9.1: Role play on history- taking with guided discussion (45 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 56 Ask if there are any questions or concerns. State the key messages (slide 16): ■ The history of the rape/sexual assault/abuse determines the examination, forensic evidence collection and treatment. ■ Before taking the history, providers should explain any obligations to report the incident to authorities and the limits of confidentiality. ■ Obtain consent separately for the history-taking, the examination and forensic evidence collection, and for reporting/sharing evidence. ■ Whether to collect forensic evidence is determined by whether the survivor wants legal redress, whether there is a legal obligation to report, whether the survivor presents within five days of sexual assault and whether staff specifically trained to do this are available. Wrap-up CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 57 Session 9a. Forensic examination (supplemental) Preparation and general information Objective 3: Demonstrate clinical skills appropriate to one’s profession and specialty to respond to violence against women. Competencies ■ Know when and how to collect forensic evidence. 60 minutes ■ Presentation with slides and with e-learning animation and guided discussion (30 minutes) ■ Exercise 9a.1: Decision-making on forensic evidence collection (30 minutes) ■ USB key or download: Clinical management of rape survivors – e-learning – Step 4 (Collecting forensic evidence) https://www.who.int/reproductivehealth/ publications/emergencies/9789241598576/en/ Tip: Check this link before your presentation. If it is working, the link on the web page will download a .zip file that you will need to un-zip in advance. ■ Exercise 9a.1: Scenarios and a table for recording responses ■ Strengthening the medico-legal response to sexual violence (WHO, UNODC, 2015) https://www.who.int/reproductivehealth/publications/violence/medico-legal- response/en/ ■ Summary of local laws and policies to prepare for context ■ Prepare in advance by reviewing the following aspects of the legal and policy context so that they can be discussed in the session. ■ Who can examine? (Any physician, nurse, forensic specialist?) What is the minimum training required? Who can act as an expert witness in court? ■ What forms are required to document forensic evidence? Who has these, or where are they kept? Who can issue/sign a medico-legal certificate? Who receives a copy of the certificate, and where are copies kept? Learning objectives and competencies Session length Training techniques Facilitator materials Accompanying reading Advance preparation for the local context CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 58 ■ Reporting For whom/when is it mandatory to report violence? ■ Storing and laboratory facilities What samples and evidence can be stored and analysed and in what time frame? What are the laws/policies regarding chain of custody of the samples? This session covers the collection of forensic evidence after sexual assault/rape. Health-care providers often consider the collection of forensic evidence to be their main role post-rape. However, their main role is, in fact, the provision of first-line support and physical and psychological care. Providers should be familiar with national laws and policies on sexual violence/ assault/abuse/rape, including laws and policies related to forensics, as well as any protocols or standard operating procedures. Who can perform the forensic examination and what training they should have received varies by country, depending on the law. Therefore, understanding the local legal context is crucial. Before starting the presentation, show the case study of Step 4 from the e-learning animation on the clinical management of rape survivors (see link above). The slides for Session 9a cover the following content: ■ Review the legal and policy context (slides 4–5) ■ Discuss the local circumstances regarding the roles, specific forms, reporting requirements and the storage and laboratory facilities available. ■ When can forensic examination be conducted? (slide 6) ■ If a woman chooses to go to the police or seek legal redress or may want to do this in the future, it can be important to collect forensic evidence. Also, the law may require it. ■ The survivor’s health and emotional well-being and safety should be the primary consideration. ■ Overview – history-taking and examination (slides 7–8) ■ A good medical history and detailed description of the sexual assault will guide the physical and forensic examination and evidence collection. ■ Maximize efforts to have only one examination by combining the physical exam and evidence collection to minimize distress and trauma. ■ Forensic examination: general tips and job aids for physical examination (slides 9–12) Background e-learning animation + presentation with slides (20 minutes) with discussion (10 minutes) Session content CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 59 ■ The head-to-toe physical exam is primarily for medical care, but it is also useful for forensic documentation. ■ Digital vaginal exam, including the “two-finger test”, SHOULD NOT be carried out to assess if rape occurred. It has no scientific validity and is a human rights violation (slide 13). ■ Forensic specimen collection, storage, documentation of findings (slides 14–18) ■ The account of the assault and the activities and time elapsed since then will determine the specimens to collect. ■ Careful labelling, documentation and storage (to avoid contamination) are essential for medico-legal evidence. ■ The absence of injuries does not mean that there was no sexual activity. ■ It is important NOT to conclude whether evidence of sexual activity indicates rape or not. That is for courts to establish (slides 19–20). Discussion ■ Ask participants if they have any questions and respond to them. ■ Refer participants to the additional reading and resources. Learning objectives for the exercise (slides 21) ■ Understand how to establish whether and when forensic evidence should be collected and what evidence should be collected. Instructions for facilitators (slide 22) ■ Divide participants into small groups of 6–8. Depending on the number of groups, assign one scenario to each group. ■ Instruct the participants to read the scenario. ■ Based on the scenario, the group should discuss the following: ■ What questions would you need to ask or what information would you need to determine how to proceed with the examination? Explain why. ■ What forensic evidence would you collect? Explain why. ■ Document the responses to the questions, including the “why” in the table provided in the handout. Guided plenary discussion ■ Ask the group: ■ Was the exercise easy to do? What was difficult? ■ What type of examination would they do, based on the scenario? ■ What would they do if the survivor did not want to go to the police? ■ Ask each group to explain their decisions and responses and the forensic evidence samples they would collect. Exercise 9a.1: Decision-making on forensic evidence collection (15 minutes) with guided discussion (15 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 60 State the key messages (slide 23): ■ Collect forensic evidence only when all 4 conditions are met: 1. Woman wants to go to police or it is mandatory. 2. Within seven days after assault. 3. Provider trained in forensic examination. 4. Forensic science lab available. ■ Separate consent is needed for a forensic examination. ■ Head-to-toe examination, but NO vaginal/“two-finger test”. ■ Assault history should guide forensic evidence collection. ■ The time elapsed and the activities after the incident will determine whether evidence can be found. ■ Storage that avoids contamination, labelling and detailed documentation are essential. ■ Health-care providers may need to provide testimony. They cannot conclude whether evidence points to rape. That is for the courts to establish. Wrap-up CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 61 Session 10. Clinical care for survivors of sexual assault/rape, part 2: treatment and care Preparation and general information Objective 3: Demonstrate clinical skills appropriate to one’s profession and specialty to respond to violence against women. Competencies ■ Know how to provide appropriate treatment/care to survivors of sexual assault, including rape and abuse. 30−60 minutes ■ Presentation with slides and guided discussion (30 minutes) ■ Exercise 10.1 (optional): Case studies on treatment for sexual assault (30 minutes) ■ Exercise 10.1 (optional): Case studies on treatment for sexual assault (includes template with blank tables) ■ Clinical handbook: Part 3 pages 39–59, Part 4 pages 67–80, Sample history and exam form pages 89–98 ■ This session covers immediate clinical care needs of survivors of sexual assault/rape. ■ While first-line support is not discussed here, note that it is part of essential care for survivors of any form of sexual violence/abuse, including rape/sexual assault. First-line support must be offered immediately in response to a disclosure of rape/ sexual assault/abuse unless there is a need to triage for more urgent and life- threatening conditions. Learning objectives and competencies Session length Training techniques Facilitator materials Accompanying reading Background Session content CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 62 ■ Providers should be familiar with national protocols, dosage, regimens and availability of emergency contraception, STI prophylaxis and HIV post-exposure prophylaxis (PEP) for both adult and child survivors of sexual assault or abuse. They should also be familiar with national laws and policy requirements related to abortion. The slides for Session 10 cover the following content (for details, see the slide notes in the PowerPoint file): ■ Conditions/symptoms that may require urgent hospitalization (slide 3) Prevention of pregnancy (emergency contraception) for women and girls who present within 120 hours (five days) (slides 4–6) ■ Pregnancy resulting from rape is a big worry for many women and girls. Providers can help them by offering emergency contraception (EC). Prevention of HIV for women and girls who present within 72 hours (slides 7–10) ■ Emphasize the time-sensitive nature of HIV post-exposure prophylaxis (PEP) – as soon as possible and no later than 72 hours. ■ Remind providers that adherence to PEP (taking one tablet each day) can face several barriers, including side-effects such as nausea and vomiting. For survivors of violence, taking PEP can trigger painful reminders of the assault. Prevention of sexually transmitted infections (slides 11–12) ■ A job aid (clinical manual, page 53) is provided to fill out with information on medication, dosage and schedule, based on national guidelines, for some of the common sexually transmitted infections (STIs) for which treatment should be offered. Self-care and follow-up visits for longer-term care (slide 13) ■ Refer to the job aids in the clinical handbook, pages 59–63, as a tool to schedule follow-up visits and communicate what signs and symptoms should be the basis for returning earlier to the clinic. Ask if there are any questions or concerns. Facilitate discussion by asking: ■ What is the current practice with respect to safe abortion for survivors of rape/sexual assault? ■ If participants are familiar with the law on provision of abortion, including in cases of rape: What are the barriers (for example, policy requirements) that may delay women and girls from accessing abortion services? Presentation with slides and guided discussion (30 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 63 Learning objective for the exercise (slide 14) ■ Improve clinical decision-making on treatments for rape/sexual assault survivors. Instructions for facilitators (slide 14) ■ Divide into groups of no more than eight participants each. ■ Each group selects a rapporteur to present back to plenary. ■ There are four case studies (handout: Sexual assault treatment decisions). Depending on the number of groups, assign one or two case studies per group. ■ Give each group 7 minutes per case study to discuss and fill out the tables describing which treatments they would prescribe, which tests they would do and which referrals they would do, and to explain why. ■ After 15 minutes (assuming two case studies per group), ask them to reconvene in plenary. ■ Ask the rapporteur from each group to present (in 3–4 minutes) one of their case studies and explain their treatment and care decisions. Ask if there are any questions or concerns. State the key messages (slide 15): ■ Immediate treatment includes first-line support and, as needed, treatment of injuries, EC, HIV PEP, STI prophylaxis and hepatitis B prevention. ■ Treatment for rape/sexual assault really depends on whether the survivor presents within the first 72–120 hours. Most survivors do not do so. ■ However, even beyond this time frame, all survivors will benefit from first-line support (LIVES), and some may need additional mental health or psychological care depending on their symptoms. ■ Providers need to determine the history of the assault and what has happened since to arrive at a decision about which tests to run and treatments to offer. Exercise 10.1 (optional): Case studies on treatment for sexual assault (30 minutes) Wrap-up CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 64 Session 11. Documenting intimate partner violence and sexual violence Preparation and general information Objective 3: Demonstrate clinical skills appropriate to one’s profession and specialty to respond to violence against women. Competencies ■ Know how to document violence against women in a safe and confidential manner. 30 minutes ■ Presentation with slides and guided discussion (30 minutes) ■ Clinical handbook, page 12 ■ Health systems manual, page 108, pages 147–156 Introduce this session by highlighting the importance of documentation to providing care and to following up. There can be adverse impacts on safety, health and justice when the provider does not adequately document the clinical management of violence or breaches the confidentiality of the survivor. In some cases, documentation can also be important as evidence if the survivor wishes to pursue a legal case. That should not be the only focus, however. Additionally, good documentation by health-care providers can help managers and policy-makers to monitor programme quality and, therefore, can be the basis for improving service delivery. Learning objectives and competencies Session length Training techniques Accompanying reading Background Session content CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 65 The slides for Session 11 cover the following content (for details, see the slide notes in the PowerPoint file): ■ Discussion of how violence against women is documented and what is documented at the participants’ facilities (see slide 2 notes). ■ The importance of confidentiality in documentation. Group brainstorm: What does confidentiality mean to you? (There can be different understandings of what confidentiality entails.) What can be the adverse consequences of breaches of confidentiality for the woman and for the provider? Discussion: How is the confidentiality of records assured in the participants’ facilities? (See slide 3 notes.) ■ Ensuring confidentiality of documents and records requires standard operating procedures (SOPs) (slide 3). ■ Managers and providers have different roles and responsibilities in ensuring confidentiality in documentation, but both are crucial (slides 4–6). Discussion of responsibility for records in the participants’ facilities (see slide 6 notes) ■ Structured forms for documentation (slides 7–9) Discussion: What should be documented? (See slide 7 notes.) The sample forms in the clinical handbook and the health systems manual are used for patient follow-up, for evidence and for programme monitoring. Refer to the following job aids: ■ Clinical handbook: physical exam checklist, page 47, and sample history and examination form, pages 89–98 ■ Health systems manual: sample intake/record form, pages 147–149, and sample facility register, page 153. Ask if there are any questions or concerns. State the key messages (slide 10): ■ Safety, confidentiality and privacy are essential. ■ Good documentation is key to providing quality care and also for legal proceedings. ■ Health managers need to establish SOPs and facilitate providers’ documentation. ■ Complete and easy-to-use forms improve documentation. Presentation with slides and guided discussions (30 minutes) Wrap-up CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 66 Session 12. Care for mental health and self-care for providers Preparation and general information Objectives ■ Demonstrate clinical skills appropriate to one’s profession and specialty to respond to violence against women. ■ Demonstrate knowledge of how to access resources and support for patients and selves. Competencies ■ Know how to provide basic mental health care. ■ Know how to access and practise self-care. 55 minutes ■ Presentation with slides and video, and guided discussion (25 minutes) ■ Exercise 12.1, Options A and B: Stress reduction exercises (15 minutes) ■ Exercise 12.2: Role play on problem-solving skills (15 minutes) ■ Clinical handbook: Part 4 (pages 67–84) ■ Responding to child and adolescent sexual abuse: WHO clinical guidelines, pages 33–38 ■ mhGAP, version 2.0. This session will help build on the skills developed in delivering first-line support to provide basic psychosocial support and to assess or identify those with mental health symptoms/conditions that need to be referred for specialized mental health care. In many settings specialized mental health services are not available. Yet there are ways that front-line workers can help survivors with their mental health in such settings. The content covered in this session is for all front-line providers, not for mental health specialists. It has been developed keeping in mind that even in low-resource settings without mental health specialists, there are some counselling, psychoeducation and interpersonal communication skills that can be strengthened among first-line Learning objectives and competencies Session length Training techniques Accompanying reading Background Session content CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 67 providers – be they doctors, nurses, midwives or counsellors – to offer basic psychosocial support. This session recognizes that, for more advanced mental health conditions, such as moderate to severe depression or PTSD, referrals to specialists (for example, psychiatrists or clinical psychologists) may be needed. This session also helps providers become aware of their own symptoms of vicarious trauma, burnout and stress that may be brought on by caring for survivors of violence. It provides tips on self-care, including stress reduction exercises. The slides for Session 12 cover the following content (for details, see the slide notes in the PowerPoint file): Basic understanding about mental health care (slide 3) ■ All women who disclose violence must receive first-line support (LIVES), as well as psychosocial support. ■ Most women can be supported by strengthening basic coping skills, including stress management. A few women may need further assessment and treatment by a specialist for mental health conditions. Offering psychosocial support (slides 4–6) ■ Front-line providers can provide basic psychosocial support, which includes positive coping methods, social support and stress reduction. ■ When a patient identifies a problem, giving advice is not the best solution. Instead, the provider should help the woman to identify problems and find her own solutions. Assess for moderate to severe mental health conditions (slides 7–12) ■ See pages 72–84 of the clinical handbook. For providers interested in learning more about managing depression, PTSD and other mental health conditions, see the mhGAP Intervention Guide at https://www.who.int/mental_health/mhgap/ mhGAP_intervention_guide_02/en/. ■ Time permitting, show a video clip by clicking on the first blue link on slide 13, under “Depression”. This video shows how a provider assesses risk for depression in a patient (7 minutes 40 seconds). Invite and answer questions. Point out that the health-care provider in the video misses the opportunity to ask about violence. Self-care for providers (slide 14) ■ Providers can experience symptoms of burnout, fatigue and vicarious trauma. If they feel this, they must seek support and professional help. They also can manage their own responses through stress reduction exercises (see instructions below). Presentation with slides and guided discussion (15 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 68 Learning objective for the exercise (slide 15) ■ Practise stress reduction exercises that providers can offer as part of basic psychosocial support and mental health care and also use themselves. Instructions for the facilitator ■ Inform participants that we will practise the stress reduction techniques recommended in the clinical handbook section on mental health care. ■ Explain that these can help people to feel calm and relaxed. Survivors can do the stress reduction exercises whenever they are stressed or anxious or cannot sleep. ■ There are two stress reduction exercises. If time permits, do both. If time is short, choose one of them. ■ Lead participants through the instructions on slides 16–18. Slow breathing technique (Option A) (10 minutes) ■ Try to keep your eyes closed. Sit with feet flat on the floor. ■ First, relax your body. Shake your arms and legs and let them go loose. Roll your shoulders back and move your head from side to side. ■ Put your hands on your belly. Think about your breath. ■ Slowly breathe out all the air through your mouth, and feel your belly flatten. Now breathe in slowly and deeply through your nose, and feel your belly fill up like a balloon. ■ Breathe deeply and slowly. You can count 1–2–3 on each breath in and 1–2–3 on each breath out. ■ Keep breathing like this for about 2 minutes. As you breathe, feel the tension leave your body. Progressive muscle relaxation technique (Option B) (10 minutes) ■ Curl toes and hold the muscles tightly. Breathe deeply; count to 3 while holding toe muscles tight. Relax toes and let out your breath. Breathe normally and feel the relaxation in the toes. ■ Do the same for each of these parts of your body in turn. Each time, breathe in deeply as you tighten the muscles, count 1–2–3, then relax and breathe out slowly. ■ Hold your leg and thigh muscles tight … 1–2–3 ■ Hold your belly tight …1–2–3 ■ Make fists with your hands …1–2–3 ■ Bend your arms at the elbows and hold your arms tight …1–2–3 ■ Squeeze your shoulder blades together …1–2–3 ■ Shrug your shoulders as high as you can …1–2–3 ■ Tighten all the muscles in your face …1–2–3 Exercise 12.1, Options A and B: Stress reduction exercises (15 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 69 ■ Drop your chin slowly towards your chest. As you breathe in, slowly and carefully move your head in a circle to the right, and then breathe out as you bring your head around to the left and back towards your chest. Do this again. And one more time. Now go the other way. Inhale to the left and back, then exhale to the right and down. Do this again. And one more time. ■ Now bring your head up to the centre. Notice how calm you feel. Discussion (5 minutes) ■ Discuss how these exercises felt for the group (for example, any positive effects, challenges) and ask if there are any questions. ■ Emphasize that these exercises can take some time to learn and encourage participants to practice at home. ■ Remind participants that these same exercises can be helpful to them as well in their daily lives and when they themselves need to remain calm and reduce the stress from caring for patients. Learning objective for the exercise (slide 19) ■ Practise problem-solving skills as a method for offering basic psychosocial support to patients. Instructions for facilitators (slide 20) ■ Form pairs. One person plays someone seeking help for a worry or concern. The second person plays a health-care provider. ■ Person seeking help: Think of a problem that you have or have had recently and are comfortable sharing with your colleague. Share your problem with the person playing the health-care provider. ■ Health-care provider: Use the five-step problem-solving approach. Ask the patient to: 1. name or identify the problem 2. describe the context of the problem 3. brainstorm solutions 4. prioritize solutions 5. make an action plan. Remember: Do not give advice. After 10 minutes, bring the group back together for discussion. Discussion (5 minutes) ■ Ask participants who played the role of the help seeker what it was like to discuss their problem with a colleague. What was especially helpful, and what could have been done differently or in addition? ■ Ask participants who played the role of the health-care provider what they felt they did well. Did they experience any difficulties with any of the steps? Exercise 12.2: Role play on problem- solving skills (15 minutes CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 70 Ask if there are any questions or concerns. State the key messages (slide 21): ■ Even in low-resource settings, front-line providers can offer basic psychosocial support. ■ Basic psychosocial support includes stress reduction exercises. ■ Assess women with continuing mental health symptoms for moderate–severe depression and PTSD. ■ Manage moderate–severe conditions or refer to mental health-care specialists. ■ Be aware of your own emotional needs. Practise self-care through stress reduction exercises, and seek professional help when needed. Wrap-up CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 71 Session 13. Addressing family planning and HIV disclosure for women subjected to violence (supplemental) Preparation and general information Objective 3: Demonstrate clinical skills appropriate to one’s profession and specialty to respond to violence against women. Competency ■ Demonstrate skills in identifying and caring for women experiencing violence who present to either family planning or HIV services. 40 minutes ■ Presentation (10 minutes) ■ Exercise 13.1: Case reviews in family planning and HIV settings (30 minutes) ■ Pros and cons of contraceptive methods in the context of violence ■ HIV disclosure counselling in the context of violence ■ Facilitator guide: Case reviews in family planning and HIV settings Intimate partner violence can be embedded in other women’s health concerns – as either a cause or an effect. For example, violence can be a barrier to contraceptive use, or contraceptive use can trigger violence. Similarly, violence can be a barrier to disclosure of HIV status, or it can result from HIV disclosure. These services, therefore, are important entry points for integration of the response to intimate partner violence. Additionally, contraceptive or HIV services need to be promoted in ways that support women’s autonomy and enhance their safety. Learning objectives and competencies Session length Training techniques Handouts Facilitator materials Background Session content CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 72 The slides for Session 13 cover the following content (for details, see the slide notes in the PowerPoint file): Why talk about IPV and family planning? (slide 3) ■ Women facing intimate partner violence lack control over their reproductive decisions. Unintended pregnancies and abortions are more common than among women not facing violence. ■ Family planning providers can support these women not only through first-line support but also by facilitating contraceptive choice and counselling in ways that take into account their needs for safety. How family planning providers can help (slides 4−6) ■ Family planning providers can learn signs of intimate partner violence and ask about violence, including reproductive coercion. ■ They can offer first-line support using the “LIVES” job aid to support women facing intimate partner violence and counsel women about contraceptive choices based on their safety concerns. Why talk about IPV and HIV status disclosure? (slides 7−8) ■ Women facing intimate partner violence may be at increased risk of acquiring STIs and HIV and are less likely to use condoms. Pathways for this include challenges in negotiating condom use, increase in risk-taking behaviours and barriers to uptake of HIV services, including risks of disclosure of status. Addressing safety in HIV status disclosure (slides 9–10) ■ Women, especially those experiencing intimate partner violence, can benefit from a provider’s help in thinking through disclosure of HIV testing and test results. ■ Providers can ask a few questions to help determine whether a woman may need a plan for safer disclosure of test results or even should not disclose. ■ Providers can help plan for safe HIV disclosure where there is fear or risk of violence. Learning objective for the exercise (slide 11) ■ Develop clinical decision-making/case management skills to respond to survivors of violence who present in family planning or HIV testing settings. Instructions for the facilitator (slide 11) ■ Set up two tables with flip charts — one for each scenario. Put a print-out of a scenario and questions at each table. Station one facilitator at each table to give instructions and facilitate discussion. If the group is too large, split into four groups and have two groups work on a scenario at the same time. ■ Divide the participants into two groups. Instruct each group to go to one of the tables. There, a participant or a facilitator will read the scenario aloud, and the group will discuss the questions. A facilitator or a volunteer member of the group will take notes on the flip chart. Presentation with slides (10 minutes) Exercise 13.1: Case reviews for family planning and HIV settings (30 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 73 ■ Allow 10 minutes for the discussion. Then the groups should discuss the other scenario. ■ Once each group has discussed each scenario (20 minutes), reconvene the entire group for discussion (10 minutes). Guiding questions for the plenary discussion ■ What difficulties did the groups have in identifying whether a person was experiencing violence? Was it easy or difficult to think about identifying signs and symptoms, conditions or behaviours? ■ What questions would you ask to determine the best course of management for that particular case? ■ What treatments or care were specific to each scenario, and what treatments or care were common for both scenarios? Ask if there are any questions or concerns. State the key messages (slide 12): ■ In various settings clinicians will need to develop additional skills to manage different cases of intimate partner violence. ■ Some aspects of care, such as first-line support, asking about violence and management of sexual assault, are standard in any setting. ■ In addition, family planning clients may need specific advice on method choice that meets their need for safety. ■ Similarly, HIV-positive women will need specific advice related to safe disclosure and negotiation of safer sex. Wrap-up CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 74 Session 14. Assessing health facility/service readiness (module for health managers) Preparation and general information Objective 2: Demonstrate behaviours and understand values contributing to safe and supportive services. Competency ■ Assess how to improve service quality and create an enabling environment for service delivery. 60 minutes ■ Presentation with slides and discussion (15 minutes) ■ Exercise 14.1: Barriers to providing care and facility readiness assessment (45 minutes) ■ Worksheet for assessing facility readiness, identifying barriers and solutions ■ Health manager’s manual, Chapter 3, pages 24–36 ■ Gender-based violence quality assurance tool Introduce the session by explaining that evidence shows that training providers is not enough in itself to deliver quality care to women subjected to violence. Training must be accompanied by institutional changes to improve service readiness and quality. We will use this session to understand barriers to facilities responding to violence, to assess service readiness of the facility and to identify priority areas for improving facility readiness. Learning objectives and competencies Session length Training techniques Handouts Accompanying reading Session content Background CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 75 Presentation (15 minutes) Slides for session 14 cover the following content. (For details, see the slide notes in the PowerPoint file.) ■ This session covers Chapter 3 of the Health manager’s manual (slides 3–4). ■ In order to improve quality of care for women subjected to violence, institutional changes are needed in addition to provider training (slide 5). Assessing service readiness ■ Job aid 3.2, can be used to assess health facility readiness (slide 6). Improving service readiness – addressing minimum requirements ■ The minimum requirements for health facility readiness (written protocol, training on first-line support (as a minimum), private setting, confidentiality, referral system and documentation) (slide 7) are covered in detail in slides 8-13. Policy readiness and political will (slides 14–16) ■ Health managers need to champion and advocate to improve service and policy readiness, including reviewing policy and legal context. Job aid 2.2 can guide this review (slide 14). ■ Managers’ advocacy can help to build acceptability among service providers to provide care and political will to improve senior management commitment in the government and with the public (slides 15–16). Learning objective for the exercise ■ To assess how ready are the services/facilities/institution to providing services. ■ To understand barriers at the service/facility/institution to providing services for women subjected to violence. ■ To identify and prioritize solutions to overcome barriers to provision of services. Instructions for facilitators ■ Divide the participants into 4 groups. If possible, participants from the same facility or institution should be in the same group. ■ Assign each group one part of the worksheet for assessment of readiness, barriers and solutions. ■ If there are multiple facilities in a group, each facility should fill out a sheet. Instructions for participants (slides 17–18) ■ Label the worksheet with the location and name of your facility/institution ■ Ask the group to review the first column, which lists facility readiness standards. Has their facility met the standard – yes, yes partially, no or don’t know. (The group should note if their facility has partially met the standard and list the details – for example, has a written protocol for sexual violence but not for IPV, or if nurses have been trained but not doctors.) Exercise 14.1: Barriers to providing care and readiness assessment (45 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 76 ■ If “partially met” or “no” (standard not met), in the third column the group should list two common barriers that impede or are likely to impede the facility’s ability to meet the standard. (If “yes” (standard met), the group can identify barriers that the facility overcame to meet the standard.) ■ Next, ask the group to list, in the solutions column, one solution to address each of the barriers to facility readiness identified as not met. ■ Last column, indicate which solution the group thinks could be implemented in the next 12 months. ■ Ask each group which of the barriers and solutions identified can be addressed with existing resources. Indicate those with a star. ■ Which of the barriers and solutions would require additional resources? Indicate those with a square. Guided plenary discussion (slide 19) ■ Ask each group to report back on up to 2 items of their self-assessment of service/ facility readiness, barriers and solutions including those that can be implemented in 12 months and with existing resources. ■ Encourage each facility/organization/institution to complete all the items of readiness after the training to assess their own readiness. Ask if there are any questions or concerns. State the key messages (slide 20). ■ Training alone is not sufficient to improve service quality. ■ Addressing barriers and improving service readiness are important to improve quality of care for women subjected to violence. ■ Requirements for facility readiness include having: ■ a written protocol ■ trained providers ■ a private space + mechanisms to ensure confidentiality ■ a documentation system ■ a referral system. ■ Mention that a job aid for a detailed assessment of facility readiness, Health facility/ service readiness: manager’s checklist, is available online in the health manager’s manual (Job aid 3.2, page 31) and that an even more detailed job aid can be found in the Gender-based violence quality assurance tool. Wrap-up CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 77 Session 15. Strengthening service readiness: improving health workforce capacity (module for health managers) Preparation and general information Objective 2: Demonstrate behaviours and understand values contributing to safe and supportive services. Competency ■ Facilitate training, supervision and mentoring of health-care providers. 65–100 minutes ■ Presentation with slides and discussion (15 minutes) ■ Exercise 15.1: Selecting staff members for training and assigning roles and responsibilities (35 minutes) ■ Alternative Exercise 15.1: A if less time: Prioritizing who will be trained in what (15 minutes) ■ Exercise 15.2: Developing a training plan (35 minutes) ■ Optional Exercise 15.3: Providing mentoring (15 minutes) ■ Exercise 15.1, Job aid 4.1 worksheet: Assigning roles and responsibilities, pages 38–39 of the Health manager’s manual ■ Exercise 15.2, Job aid 4.2 worksheet: Considerations for a training plan, pages 41–43 of the Health manager’s manual ■ Health manager’s manual, Chapter 4, pages 37–50 Evidence shows that one-off training is not enough to build the capacity of health workers to care for women subjected to violence. Sustained capacity requires assigning roles and responsibilities appropriately to staff members, training those staff members, and then providing mentoring, supportive supervision and refresher training to support them in their daily work. It also needs to be reinforced with job aids and reminders. Learning objectives and competencies Training techniques Accompanying reading Background Session content Handouts Session length CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 78 Slides for this presentation cover the following content. (For details, see the slide notes in the PowerPoint file.) ■ Overview of the session (slides 3–4) Assigning roles and responsibilities (slide 5) ■ It is important, where possible, to train across different cadres that can work together to provide care. ■ A trained staff should be available (or on call) at all times of the day and night for sexual assault response. Training principles, tips and plan ■ Emphasis should be on skills-based learning that is part of an on-going process rather than one-off (slide 6). ■ Support training by participating yourself, giving time for staff to participate and giving credit to staff who complete training (slide 7). ■ A training plan should address objectives, outcomes, content, logistical details, facilitation and resources required as well as methods of evaluating quality and achievement of objectives (slide 8). Mentoring and supervision to support performance (slides 9–11) ■ Mentoring and supervision are meant to support staff and find solutions. They work best through respectful dialogue rather than fault finding. ■ Mentoring takes place after training, by reviewing cases and providing feedback. ■ Supervision ensures that providers apply new skills correctly, by assessing performance and helping to solve problems. Support providers to practice self-care/address vicarious trauma (Slide 12) ■ Recognize providers’ needs for emotional health, vicarious trauma and burnout ■ Facilitate providers to get the help and support they need for themselves (e.g. counselling, breaks) ■ Teach them and help them practice stress reduction techniques (the same techniques used to help survivors can be practiced by providers) Learning objective for the exercise (slide 13) ■ To identify and select those health care providers who are motivated and ready to be trained. ■ To assign tasks for care of survivors to health care providers in accordance with their roles and responsibilities. Instructions for facilitators ■ Divide participants, if possible, into groups from the same facility or district, or from the same unit/department within a facility, so that they can complete this exercise based on their own staffing. Presentation (15 minutes) Exercise 15.1: Selecting staff members for training and assigning roles and responsibilities (35 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 79 ■ Ask each group to list roles and responsibilities of various cadres of health providers on a flip chart, following the template on slide 14. Instructions for the participants ■ Select a rapporteur and a facilitator. ■ List the different cadres of health workers/staff in the facility or unit who interact with patients and those that document cases. ■ For each cadre, list their roles and responsibilities in the facility, focusing on those that require them to interact with patients and those that require them to fill out patient records or facility registers to document details about their condition. ■ Review the handout – Exercise 15.1 - Job aid 4.1 work sheet (Chapter 4, pages 38– 39) (slide 15). Based on the roles and responsibilities of different cadres, fill out job aid 4.1 worksheet by assigning to each task the cadre of health worker who is best suited to carry out that task with skills that can be enhanced through training. ■ This, then, will be the basis of identifying and selecting the cadres of health workers who will be prioritized for the training. ■ Note: Afterwards in your health facility, discuss the training opportunity with each staff member, ask them about their motivations to provide care for survivors of violence, the challenges they may face, and then finalize the list of health workers who will be prioritized for training based on their motivations and their roles and responsibilities. ■ When completed and confirmed, job aid 4.1 can be posted in the facility or unit/ clinic. Learning objective ■ To prioritize which cadres of health providers will receive training based on their roles and responsibilities (Slide 16). Instructions for facilitators ■ Divide participants, if possible, into groups from the same facility or district, or from the same unit/department within a facility, so that they can complete this exercise based on their own staffing. ■ Read Scenario: you have been asked by the Gender Ministry in your country to develop a training plan to integrate the health response to violence against women into SRH and HIV services. ■ Ask the groups to respond to the following three questions on a flip chart. (Slide 16) ■ Which cadres of service providers will you prioritize for training? ■ What content will you cover in the training: list at least 3-4 priority topics? ■ How will you assess whether the training has led to improvement in skills and actual practice of providers? ■ Reconvene them in plenary after 10 minutes to report back on the three questions. Ask the first group to only report on one point per question. Ask the subsequent Exercise 15.1A if time is short (15 minutes): Alternative to Exercise 15.1: Prioritizing who will be trained in what. CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 80 groups to add one point per question that is not already covered by the previous group Instructions for participants ■ Select a rapporteur and a facilitator. ■ Discuss and respond to each question on a flip chart. Use the guidance for training considerations provided in Job aid 4.2 to answer the questions on the flip chart. Report back in plenary responses to each of the three questions, focusing on only 1 point per question. If a point has already been raised by another group, do not repeat, and only add new points that are missing. Learning objective ■ To develop a staff training plan for responding to women subjected to violence (Slide 17). Instructions for facilitators ■ Keep the same small groups as for the previous exercise. ■ Distribute to each group the handout Exercise 15.2- Job aid 4.2 worksheet (manager’s manual, pages 41–43; overview of the topics covered in worksheet on slide 18). ■ Ask the groups to fill the handout – Exercise 15.2- Handout Job aid 4.2 worksheet. ■ Reconvene in plenary and ask each group to put up their training plans on the wall and invite all the participants to walk through and read them during break time. ■ Ask one person from each group to be present and answer any questions from others who come by to see their training plans Instructions for participants ■ Select a rapporteur and a facilitator. ■ Discuss and respond to the following question or issues on the worksheet: purpose and outcomes of training; training content; who will be trained; how will training outcome be assessed; and how will quality performance be sustained after the training. Write down the specific decisions that the group makes about the training purpose, content, who will be trained, and how the training will be conducted following the guidance provided in Job aid 4.2. ■ For the remaining aspects of a training plan – i.e. who will conduct training, how will it be conducted, length, format, agenda, location – please complete these after this session in consultation with your staff/team. Use Job aid 4.2 to answer the questions and fill out the template. Learning objective ■ To learn how to provide mentoring support to health providers who have been trained and are caring for women subjected to violence. Exercise 15.2: Developing a training plan (35 minutes) Optional Exercise 15.3: Providing mentoring (15 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 81 Instructions for facilitators (slides 19–20) ■ Divide participants, if possible, into groups from the same facility or district, or from the same unit/department within a facility, so that they can complete this exercise based on their own staffing. ■ Read Scenario: You have overseen a training of 50 health care providers in your district/province who have now been practicing what they learned for 6 months. You conduct a follow up assessment and find that while knowledge and attitudes toward survivors has improved and most providers are identifying cases of IPV, they are still not offering all aspects of first-line support – particularly safety planning with survivors. You also find that some of the younger providers are feeling stressed by listening to stories about survivor abuse when they identify cases. ■ Ask the groups to respond to the following questions on a flip chart. ■ As a manager, what will you do to identify why providers cannot offer all aspects of first-line support and, in particular, safety-planning to survivors? ■ What will you do to improve this aspect of clinical practice? (list 2 ideas for supportive supervision and 2 ideas for mentoring). ■ How will you support the younger providers who are feeling stressed or experiencing vicarious trauma? ■ Reconvene them in plenary after 10 minutes to report back on the three questions. Ask the first group to report only on one point per question. Ask the subsequent groups to add one point per question that is not already covered by the previous group. Instructions for participants ■ Discuss and respond to each question on a flip chart. ■ Report back in plenary responses to each of the three questions, focusing on only 1 point per question. If a point has already been raised by another group, do not repeat, and only add new points that are missing. State the key messages (slide 21). Training needs to: ■ be ongoing and bolstered by mentoring and supervision ■ work with teams of different cadres of health workers based on the roles, responsibilities and motivations of different health workers ■ be competency-based ■ be interdisciplinary – training different cadres and sectors together as well as holding separate sessions for each cadre. Wrap-up CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 82 Session 16. Strengthening service readiness: improving infrastructure for privacy, ensuring supplies (module for health managers) Preparation and general information Objective 2: Demonstrate behaviours and understand values contributing to safe and supportive services. Competency ■ Planning to improve infrastructure and procurement of equipment and supplies. 60–90 minutes ■ Presentation (5 minutes) ■ Exercise 16.1: Patient flow mapping to assess infrastructure needs for privacy (45 minutes) ■ Exercise 16.1A: Improving privacy in facilities (15 minutes) – Alternative if time is short ■ Presentation (10 minutes) ■ Exercise 16.2: Reviewing list of equipment, medicine and other supplies (30 minutes) For exercise 16.1: ■ Case descriptions of 2 patients + Template for patient flow mapping, printed on an A3 sheet (where possible) For exercise 16.2: ■ Job aid 5.2 worksheet: checklist of equipment, medicines and other supplies, printed on an A3 sheet (where possible). ■ Health manager’s manual, chapter 5, pages 51–58 ■ Handout Job aid 5.1 – Infrastructure considerations, barriers and suggestions to overcome them (template printed on A3 sheet – where possible). The worksheet can be completed after the training in consultation with facility staff. Learning objectives and competencies Session length Training techniques Accompanying reading Handouts CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 83 Session content Equipping a health facility to respond to violence against women requires both the infrastructure to assure privacy and the equipment, medicines and other supplies necessary to provide care. Privacy and confidentiality are some of the minimum health system requirements for health-care providers to ask women about their experience of violence and to respond to their needs. Additionally, facilities need to have on hand the equipment, medicines and other supplies required to care for survivors of violence and to include them in the list of essential supplies that are regularly procured and stocked. Slides for this presentation cover the following content. (For details, see the slide notes in the PowerPoint file.) ■ Overview of the session (slides 3–4) ■ The facility manager’s roles in ensuring a private setting (slide 5) ■ The district, regional or national policy-makers’ roles in ensuring a private setting (slide 6). Learning objectives for the exercise (slide 8) ■ Map patient flow through the facility/clinic to identify: ■ the points where clients interact with various health-care providers and where women are likely to be asked about violence with the potential to breach privacy and confidentiality ■ options for rerouting patient flow in order to improve privacy, confidentiality and reduce the need for women to have to retell their history repeatedly. Instructions for facilitators (slides 9–10) ■ If possible, form small groups of participants from the same facility or the same unit/department so that they can apply this exercise to their setting. If any facilities only have 1 participant, combine these with other facilities. ■ Give half the groups the case study of a survivor of sexual assault who specifically comes to seek care for this (Case study 1) and give the other half the case study of the survivor of intimate partner violence who has not disclosed the violence but comes to the facility for ANC (Case study 2). ■ Ask the group to draw the template on the flip chart and then draw a patient flow chart showing how their case study client would proceed through their facility. Review with the group the instructions on the exercise handout. It may be helpful to show the group a finished example of a patient flow chart on the template. ■ After 20 minutes, ask the groups to look at where in the patient flow the survivor can be asked – and by which providers – about her experience of violence. Ask the participants to consider privacy, confidentiality, time available and limiting the number of times she is asked about her experience (refer to job aid 5.1 (slide 7) for privacy and confidentiality sensitive areas and potential solutions to overcome these). Background Presentation (5 minutes) Exercise 16.1: Patient flow mapping to assess infrastructure needs for privacy (45 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 84 ■ For points in the patient flow marked “NP” (no privacy) or “CB” (possible confidentiality breach), discuss how privacy and confidentiality can be enhanced (10 mins) Ask the groups to add their privacy and confidentiality enhancing practices on the flip chart documenting the patient flow mapping. Guided plenary discussion (slide 11) ■ Discuss the patient flow, any areas where the groups are going to improve these based on the needs for providers, for the infrastructure, or other needs. Specifically focus on critically examining the situation and overcoming barriers. Instructions for facilitators (slides 12 and 13) ■ Project pictures on slide 13 (in zoom so that they are clearly visible) for all participants to see them. There are 6 pictures numbered from 1 to 6 ■ For each picture, ask the participants in plenary the following two questions: 1. How does the setting reflected in the picture promote or not promote privacy and confidentiality for the survivor? 2. Provide one suggestion to improve or to have a private and confidential consultation with the survivor for each of the pictures. ■ On a flip chart for each picture numbered 1 to 6, on the left side record observations of participants on how the setting does or does not ensure privacy and confidentiality for the survivor. On the right side record observations about the suggestions they have for improving privacy and confidentiality. Slides for this presentation cover the following content. (For details, see the slide notes in the PowerPoint file.) ■ Managers’ considerations in deciding what equipment, medicines and other supplies are needed at each level of the health-care system (slide 14) ■ Job aid 5.2, the checklist of necessary equipment, medicines and other supplies (slide 15) ■ The facility manager’s roles (slides 16–17) ■ The roles of district, regional or national policy-makers (slide 18) Learning objectives for the exercise (Slide 19) ■ To determine what equipment, medicines and other supplies are missing. ■ To determine how they can be obtained. Instructions for facilitators (Slide 19) ■ If possible, form groups of participants from the same facility or the same unit/ department so that they can apply this exercise to their setting. If there are facilities/units/departments from which only one participant joined, ask them to join another group, but fill out the form separately. Exercise 16.1A – Assessing and improving privacy in facilities (Alternative exercise if less time) (15 minutes) Presentation (10 minutes) Exercise 16.2: Reviewing list of supplies, equipment and medicines (30 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 85 ■ Distribute the handout – Exercise 16.2 Job aid 5.2 worksheet, Checklist of equipment, medicines and other supplies. ■ For each item on the checklist, ask participants to mark whether or not it is 1) available in the facility and 2) physically stocked where the consultation and examination of the woman takes place (slide 17). ■ Discuss and record in the notes section of the worksheet any challenges related to availability of specific supplies, medicines or equipment. For example, they may be expensive or not on the list of essential medicines, or the exact formulation is not available in the market or for procurement. Guided plenary discussion (slide 20) Invite participants to compare their answers to these questions: ■ Which equipment, supplies & medicines are typically lacking? ■ Why are they lacking? Across facilities, are there common or diverse barriers? ■ How can the barriers be overcome? Ask if there are any questions or concerns. State the key messages (slide 21). ■ Patient flow, infrastructure and record-keeping should ensure privacy and confidentiality throughout, but especially in every consultation where violence might be discussed. ■ Managers should use the supplies checklist in Job aid 5.2 to see what needs to be ordered and what needs to be stocked to ensure a full supply of what is needed where consultations take place. Wrap-up CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 86 Session 17. Preventing violence against women (supplemental) Preparation and general information Objective 3: Demonstrate clinical skills appropriate to one’s profession and specialty to respond to violence against women. Competencies ■ Understand how to enhance protective factors, minimize risk and mitigate harmful consequences of violence against women. ■ Know about multisectoral prevention strategies that the health sector can promote or advocate with other sectors. ■ Identify prevention strategies that can be implemented by health-care providers. 105 minutes ■ Presentation (15 minutes) ■ Exercise 17.1: Lifeline and problem tree to identify risk, protective factors and consequences of violence against women (75 minutes) ■ Exercise 17.2: Solutions tree – brainstorming health promotion messages and activities for prevention in the health sector (15 minutes) ■ Assess the risk and protective factors ■ Examples of health promotion messages addressing violence against women ■ 7 “RESPECT” posters. Available at: https://www.who.int/reproductivehealth/ Respect-A3Posters.pdf?ua=1 ■ RESPECT women: Preventing violence against women. Geneva: WHO, 2019. Available at: https://www.who.int/reproductivehealth/publications/preventing- vaw-framework-policymakers/en/. Learning objectives and competencies Session length Handouts Training techniques Accompanying reading CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 87 Session content A public health approach to violence against women includes a focus on prevention. Even as the primary role of health-care providers is to address the health and psychosocial needs of survivors of violence, the health sector also has an important role to play in the prevention of violence against women. This involves having a good understanding of factors that contribute to an increased risk of violence (‘risk factors’) and conversely those that reduce the risk (‘protective factors’) for violence, enhancing protective factors and reducing risks to stop violence from happening in the first place. It also involves preventing recurrence of violence, including by mitigating harmful consequences of such violence. This session will cover an understanding of risk and protective factors for violence against women and introduce participants to RESPECT women: Preventing violence against women, a package of 7 strategies for prevention. This session will help participants identify those strategies that can be implemented through the health services, including through health promotion activities. Slides for this presentation cover the following content. (For details, see the slide notes in the PowerPoint file.) ■ A summary of what is known globally about risk and protective factors for being subjected to and for men perpetrating intimate partner violence and sexual violence against women (slides 3–10). ■ Explaining the continuum of prevention: primary, secondary, and tertiary (slide 11). ■ An introduction to RESPECT women: A framework for preventing violence against women. Each letter of the word “RESPECT” stands for a strategy, as follows: R – relationship skills strengthened E – empowerment of women S – services ensured P – poverty reduced E – enabling environments created C – child and adolescent abuse prevented T – transformed attitudes, beliefs and norms (slides 12–13). ■ You may choose to show the rap video on RESPECT and, if appropriate, as a stretch break, play the Aretha Franklin song “Respect” and ask the group to stand and act out with their hands and bodies the 7 letters of “RESPECT” (https://www.who.int/ reproductivehealth/publications/RESPECT-women-infographics/en/) (slide 14). ■ Evidence on interventions that can be implemented through health services, including health promotion activities (slide 15). ■ Guiding principles for implementing prevention programmes, drawing on principles of participation, gender equality and human rights (slide 16). Background Presentation (15 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 88 Learning objectives for the exercise ■ To build understanding of risk and protective factors and of root causes, risk factors and consequences of violence against women as the basis for prevention strategies Instructions for facilitators (slides 17–20) ■ The group will be split up to do two different exercises in smaller groups. Divide the participants into groups of 6–8 each (slide 17). ■ Half of the groups will do a lifeline exercise to understand risk and protective factors. The other half will draw a problem tree to map out the root causes, risk factors and consequences of violence against women. First explain the lifeline exercise, and subsequently the problem tree exercise. ■ Case study 1 is of a 16-year-old girl from a family of 6 who has experienced sexual abuse since childhood (slide 18). ■ Case study 2 is that of a 25-year-old man who is abusing his wife and his two children; he has a sexually transmitted infection (slide 18). Lifeline exercise (slide 19) ■ Ask the groups working on the lifeline exercise to use Case study 1 and create a story about the 16-year-old girl from the time she was a baby to the time she will be much older. The story should identify the positive and negative events in her life from birth to older age. ■ Ask the group to draw, on a flip chart sheet in landscape format, a line in the middle and mark one end of the line as birth and the other end as older age, around 70 years. They also can mark a point representing her current age of 16 years. Slide 19 (show) provides a template. The groups can add blocks for more events. ■ In the blocks above the line, the group records positive events that may have happened or could occur from birth through the time that abuse began through her current age and beyond into old age. Below the line the groups record adverse, or negative events that may have happened or may occur. Ask the group to be realistic to their setting in writing these factors. ■ Explain that positive events can be considered protective factors and negative events are risks or risk factors. Ask the groups to identify and write down what interventions could amplify the positive, or protective, factors and what interventions can mitigate or reduce the negative, or risk, factors. The group can write these on post-it notes and stick them on their chart. ■ Ask the groups then to indicate with a star which interventions could be implemented directly by the health services and which could the health services work with or advocate with other services (for example, schools, child protection services, economic or livelihood services, police, legal services). Exercise 17.1: Assessing risk, protective factors and consequences of VAW: lifeline and problem tree exercise (75 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 89 Problem tree exercise (slide 20) ■ Ask the groups working on the problem tree exercise to use Case study 2 of the 25-year-old man with a wife and two children. Ask them to draw on a flipchart a tree with roots, trunk and branches, as shown on slide 20 (show slide). ■ Ask the groups to develop a story for this man in terms of what are the root causes that contribute to him abusing his wife, what are some of the risk factors and what are the consequences of his abuse for himself, his wife and his children. Root causes can be written near the tree roots, risk factors written near the trunk and consequences written in the branches. Be realistic in what all of these may be in your setting. ■ Ask the group to brainstorm what interventions, services or programmes could address the root causes of his violence and the risk factors and what interventions could mitigate, or reduce, the negative or harmful consequences of violence for himself, his wife and children. The group can write these on post-it notes and stick them on their chart. ■ Ask the groups then to indicate with a star which interventions, services or programmes could be implemented through the health services. Guided plenary discussion ■ Ask a volunteer from one lifeline group and one problem tree group to show their chart and describe their case studies’ stories, their analysis of risk and protective factors and the interventions that they identified, pointing out which could be implemented through health services. ■ Ask other groups to add only factors and interventions not already covered by the first two groups, to avoid repetition. The facilitator can ask a notetaker to write down the different interventions proposed. ■ Discuss which of the interventions proposed could be feasibly implemented through the health sector in their settings. Instructions for facilitators ■ On a flip chart draw a solutions tree like that on slide 21 (or print one from the slide) ■ Ask each group to brainstorm for 10 minutes and to write on one post-it or note card: ■ one message regarding prevention of violence against women that they would want to communicate to their patients or in their communities ■ one facility activity into which they could incorporate this key message (for example, counselling, pamphlet, wall poster, alcohol or drug abuse prevention counselling) (refer to the handout on examples of health promotion messages addressing violence against women) ■ one activity that they conduct outside the facility where they could deliver the prevention message (for example, radio show, community outreach, speeches/ presentations to the health community/associations or in their communities). Exercise 17.2: Solutions tree: brainstorming health promotion messages and activities for prevention in the health sector (15 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 90 ■ Ask each group to put their post-it notes or cards with the key messages at the roots, the information about facility activity on the trunk and the outside the facility activity on the branches. ■ Close the exercise by reading a few of the groups’ ideas for key messages, activities within the facility, and activities outside the facility for promoting prevention of violence against women. Ask if there are any questions or concerns. State the key messages (slide 22). ■ Violence against women is preventable. ■ The health sector has a role to play in prevention in addition to providing health services. ■ To design ways to prevent violence, we need to understand risk and protective factors and consequences and to develop interventions that enhance protective factors and reduce risk and harmful consequences. ■ The RESPECT framework can help to identify promising prevention strategies and guiding principles for implementing them. Health sector prevention can be implemented through several of the RESPECT strategies – for example, R – relationship skills strengthened; S – services ensured; C – child and adolescent abuse prevented; and T – transformed attitudes, beliefs and norms. ■ As health-care professionals, you can incorporate messages about prevention into health promotion activities, implement interventions through other services and programmes, including in mental health, alcohol and drug abuse services or prevention plans, and in your capacity as community leaders and advocates with your peers, in communities and with other leaders. Wrap-up CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 91 Conclusion Preparation and general information 20–40 minutes ■ Guided discussion on moving beyond training to strengthen capacity (10 minutes) ■ Post-training feedback form (10 minutes) ■ Post-training survey/assessment (optional) (20 minutes) ■ Copies of post-training feedback form ■ Copies of post-training survey/assessment (optional) (available on request) Thank the participants for their participation. Revisit the questions and fears raised throughout the training, including from the "Fear and Motivations in a Hat” exercise in the first session, and answer any remaining questions. Conclude the training by reminding participants of their important role in responding to violence against women. Remind them that first-line support, including active, supportive listening, is an important step in restoring self-confidence to survivors. Remind them that, while this training builds knowledge, skills and confidence, learning is an ongoing process and that after the training, to keep up with skills and knowledge, it is important to go through: ■ Refresher sessions focusing on areas/topics/skills that are the most challenging to implement ■ Case management reviews, which include discussing how difficult cases are handled and what can be done to improve care and management ■ Assessing improvements in quality. Encourage them to continue practising their skills and to turn to their colleagues in this training for support. (For example, some groups have created a WhatsApp group to keep in touch.) Session length Training techniques Facilitator materials Guided discussion (10 minutes) Session content CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 92 Remind them to rely on the clinical handbook, handouts from this training and their colleagues for ongoing support. Ask participants if they have any questions to conclude, or next steps that they would like to discuss to improve their own or workplace/institutional response to violence against women. Ask participants to reflect on and write down at least three steps that each of them can take to strengthen clinical management of violence for patients who seek care in their work setting. Remind participants that an e-learning course will be available and that they can use it to reinforce their skills or remind themselves of specific aspects. Distribute the form for evaluation of the training, and ask participants to complete it. Their responses will be used to inform and improve future training. Optional: If you are evaluating the training as part of a project, pilot or just to improve quality, you also can administer a post-training survey questionnaire (20 minutes) to assess changes in knowledge and attitudes from the baseline. Again, thank the participants for attending and for participating. Post-survey (10–20 minutes) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 93 References and supplemental reading Chang JC, Decker MR, Moracco KE, Martin SL, Petersen R, Frasier PY. Asking about intimate partner violence: advice from female survivors to health care providers. Patient Educ Couns. 2005;59(2):141–147 (http://www.sciencedirect. com/science/article/pii/S0738399104003404?via%3Dihub, accessed 27 November 2018). Chang JC, Dado D, Hawker L, Cluss PA, Buranosky R, Slagel L, McNeil MA, Scholle SH. Understanding turning points in intimate partner violence: Factors and circumstances leading women victims toward change. J Women’s Health. 2010;19(2):251-9. García-Moreno C, Hegarty K, d’Oliveira AFL, Koziol-MacLain J, Colombini M, Feder G. The health-systems response to violence against women. Lancet. 2015;385(9977):1567–79 (http://www.thelancet.com/pdfs/journals/lancet/ PIIS0140-6736(14)61837-7.pdf, accessed 21 July 2018). WHO multi-country study on women’s health and domestic violence against women. Summary report – Initial results on prevalence, health outcomes and women’s responses. Geneva: World Health Organization; 2005 (http://www.who.int/reproductivehealth/publications/violence/9241593512/en/, accessed 21 July 2018). Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. Geneva: World Health Organization; 2013 (http://www.who.int/reproductivehealth/publications/ violence/9789241548595/en/, accessed 21 July 2018). Health care for women subjected to intimate partner violence or sexual violence: a clinical handbook. Geneva: World Health Organization; 2014 (http://www.who.int/reproductivehealth/publications/violence/vaw-clinical- handbook/en/, accessed 21 July 2018). Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infections: recommendations for a public health approach – 2nd edition. Geneva: World Health Organization; 2016, Chapter 3 (https://apps.who.int/iris/bitstream/handle/10665/208825/9789241549684_eng.pdf?sequence=1, accessed 21 July 2018). Selected practice recommendations for contraceptive use – 3rd edition. Geneva: World Health Organization; 2016 (https://apps.who.int/iris/bitstream/handle/10665/252267/9789241565400-eng.pdf?sequence=1, accessed 21 July 2018). WHO guidelines for the treatment of Chlamydia trachomatis. Geneva: World Health Organization; 2016 (https://apps.who.int/iris/bitstream/handle/10665/246165/9789241549714-eng.pdf?sequence=1, accessed 21 July 2018). WHO guidelines for the treatment of genital herpes simplex virus, Geneva: World Health Organization; 2016 (https://apps.who.int/iris/bitstream/handle/10665/250693/9789241549875-eng.pdf?sequence=11, accessed 21 July 2018). WHO guidelines for the treatment of Neisseria gonorrhoeae. Geneva: World Health Organization; 2016 (https://apps.who.int/iris/bitstream/handle/10665/246114/9789241549691-eng.pdf?sequence=1, accessed 21 July 2018). WHO guidelines for the treatment of Treponema pallidium (syphilis). Geneva: World Health Organization; 2016 (https://apps.who.int/iris/bitstream/handle/10665/249572/9789241549806-eng.pdf?sequence=1, accessed 21 July 2018). Responding to children and adolescents who have been sexually abused: WHO clinical guidelines. Geneva: World Health Organization; 2017 (http://who.int/reproductivehealth/publications/violence/clinical-response-csa/en/, accessed 21 July 2018). CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 94 Strengthening health systems to respond to women subjected to intimate partner violence or sexual violence: a manual for health managers. Geneva: World Health Organization; 2017 (http://www.who.int/reproductivehealth/ publications/violence/vaw-health-systems-manual/en/, accessed 21 July 2018). RESPECT women: preventing violence against women: A framework for policy makers. Geneva: World Health Organization; 2019 (https://apps.who.int/iris/bitstream/handle/10665/312261/WHO-RHR-18.19-eng.pdf?ua=1) WHO, UNODC. Strengthening the medico-legal response. Geneva: World Health Organization; 2015 (https://apps. who.int/iris/bitstream/handle/10665/197498/WHO_RHR_15.24_eng.pdf?sequence=1&isAllowed=y, accessed 21 July 2018). WHO, LSHTM, SAMRC. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva: World Health Organization; 2013 (https://apps. who.int/iris/bitstream/handle/10665/85239/9789241564625_eng.pdf?sequence=1, accessed 21 July 2018). Young-Wolff KC, Kotz K, McCaw B. Transforming the health care response to intimate partner violence addressing “wicked problems”. JAMA. 2016;315(23):2517–18 (http://jamanetwork.com/journals/jama/fullarticle/2529639, accessed 21 July 2018). CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 95 Annex 1. Training timings and sample agendas Training schedule for health care providers Length Session Core content only Optional content Optional: Ministry introduction — 20–30 minutes Orientation and introductions Optional: Pre-training assessment 60 minutes 20 minutes Session 1. Understanding violence against women as a public health problem Optional: Country-level presentations 40 minutes 15 minutes Session 2. Understanding the survivor’s experience and how providers’ values and beliefs affect the care they give Optional: Additional exercises 80 minutes 40–60 minutes Session 3. Guiding principles and overview of the health response to violence against women 30 minutes — Session 4. Provider–survivor communication skills 45 minutes — Session 5. When and how to identify intimate partner violence Optional: Shorter or longer exercise 40 minutes 30 minutes Session 6. First-line support using LIV(ES), part 1: Listen, Inquire, Validate 105 minutes — Session 7. Know your setting: identify referral networks and understand the legal and policy context (#) Optional: Additional exercise and invited guest 70 minutes 30–60 minutes Session 8. First-line support using (LIV)ES part 2: Enhancing safety and providing Support 95 minutes — Session 9. Clinical care for survivors of sexual assault/rape, part 1: history-taking and examination 75 minutes — Session 9a. Forensic examination (supplemental) — 60 minutes Session 10. Clinical care for survivors of sexual assault/rape, part 2: treatment and care Optional: Additional exercise 30 minutes 30 minutes Session 11. Documenting intimate partner violence and sexual violence 30 minutes — Session 12. Care for mental health and self-care for providers 55 minutes — Session 13. Addressing family planning and HIV disclosure for women subjected to violence (supplemental) — 40 minutes Session 17. Preventing violence against women (supplemental) — 105 minutes Conclusion Optional: Post-training assessment 20 minutes 20 minutes Closing and certificate ceremony (optional) — 20–30 minutes Total time ~13 hours ~7.25–9.25 hours # For these sessions it is useful to have the participation of other sectors (for example, police, legal, protection, social services, NGOs). CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 96 Sample agendas The full 13 sessions are usually delivered in two and a half days, and experience suggests that this is the minimum required. However, if necessary you can cover sessions 1–12 in two days. If less than two days are available, you will need to adjust the content to fit the time available. We suggest covering sessions 1 through 8 to ensure that LIVES is fully covered. Another option is to present half-day sessions over several weeks. Some settings have come back for remaining or repeated sessions six months later as part of a refresher. The sample agendas below give examples of 2.5-day, 2-day and 1-day agendas. You will want to adapt for local context and time considerations. Be sure to allow for time for energizers when the group needs it, especially in the afternoons. Day 1 9:00–9:30 Opening ceremony Welcome and introductory remarks 9:30–10:30 Orientation and introductions 10:30–10:45 Break 10:45–11:25 Session 1. Understanding violence against women as a public health problem (additional time may be needed for country presentations) 11:25–12:45 Session 2. Understanding the survivor’s experience and how providers’ values and beliefs affect the care they give 12:45–1:15 Session 3. Guiding principles and overview of the health response to violence against women 1:15–2:15 Lunch 2:15–3:00 Session 4. Provider–survivor communication skills 3:00–3:40 Session 5. When and how to identify intimate partner violence (without optional exercise) 3:40–3:55 Break 3:55–5:40 Session 6. First-line support using LIV(ES), part 1: Listen, Inquire, Validate Day 2 9:00–10:40 Session 7. Know your setting: identify referral networks and understand the legal and policy context (with optional exercise or invited guest) 10:40–10:55 Break 10:55–12:30 Session 8. First-line support using (LIV)ES, part 2: Enhancing safety and providing Support 12:30–1:30 Lunch 1:30–2:45 Session 9. Clinical care for survivors of sexual assault/rape, part 1: history-taking and examination 2:45–3:00 Break 3:00–4:00 Session 10. Clinical care for survivors of sexual assault/rape, part 2: treatment and care (with optional exercise) 4:00–4:30 Session 11. Documenting intimate partner violence and sexual violence 2.5-day agenda CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 97 Day 3 9:00–9:55 Session 12. Care for mental health and self-care for providers 9:55–10:35 Session 13. Responding to intimate partner violence and sexual violence in different service delivery settings: family planning and HIV (supplemental session) 10:35–10:50 Break 10:50–11:35 Preventing violence against women 11:35–12:00 Conclusion 12:00–12:45 Closing certificate ceremony 12:45–14:00 Lunch (optional) 2-day agenda, core content only Day 1 9:00–10:00 Orientation and introductions 10:00–10:40 Session 1. Understanding violence against women as a public health problem (additional time may be needed for country presentations) 10:40–10:55 Break 10:55–12:15 Session 2. Understanding the survivor’s experience and how providers’ values and beliefs affect the care they give 12:15–12:45 Session 3. Guiding principles and overview of the health response to violence against women 12:45–1:45 Lunch 1:45–2:30 Session 4. Provider–survivor communication skills 2:30–3:10 Session 5. When and how to identify intimate partner violence (without optional exercise) 3:10–3:25 Break 3:25–5:10 Session 6. First-line support using LIV(ES), part 1: Listen, Inquire, Validate Day 2 9:00–10:10 Session 7. Know your setting: identify referral networks and understand the legal and policy context (without optional exercise or invited guest) 10:10–10:45 Session 8. First-line support using (LIV)ES, part 2: Enhancing safety and providing Support 10:45–11:00 Break 11:00–12:00 Continued: Session 8. First-line support using (LIV)ES, part 2: Enhancing safety and providing Support 12:00– 1:15 Session 9. Clinical care for survivors of sexual assault/rape, part 1: history-taking and examination 1:15–2:15 Lunch 2:15–2:45 Session 10. Clinical care for survivors of sexual assault/rape, part 2: treatment and care 2:45–3:00 Break 3:00–3:30 Session 11. Documenting intimate partner violence and sexual violence 3:30–4:25 Session 12. Care for mental health and self-care for providers 4:25–5:00 Conclusion and post-training assessment CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 98 1-day agenda for obstetricians and gynaecologists Objectives: 1. Raise awareness and increase the understanding of obstetrics and gynaecology practitioners on violence against women as a women’s health and public health issue. 2. Familiarize obstetricians and gynaecologists with existing tools and good practices for building clinical knowledge and skills on the response to survivors of violence, including identification of partner violence, first-line support (LIVES), principles of survivor-centred care and post-rape care. Time Topic Minutes Method Morning session 9:00–9:20 Welcome and brief opening remarks by the organizers Presentation of the workshop objectives 20 9:20–10:00 Introductions Fear in a Hat exercise (participants will be asked to share one challenge/fear of addressing VAW) (from Orientation session) 40 Participatory exercises 10:00–11:00 Understanding VAW as a public health problem: definitions, prevalence, health consequences, role of the health-care provider (from Session 1) 60 Presentation, Animation video, Questions & Answers 11:00–11:15 Coffee/tea break 15 11:15–12:00 Myths and Facts: Vote with your Feet (from Session 2) 45 Participatory exercise 12:00–12: 45 ■ Principles of women-centred care (from Session 3) ■ Identification of women subject to violence (from Session 5) ■ First line support (LIVES), and referral (from Sessions 6 and 8) 45 Presentations, Videos, Questions & Answers 12:45–13:45 Lunch 60 Optional: local or regional video Afternoon session 13:45–14:45 Responding to violence in different contexts – discussion of case scenarios (from Session 13 or others depending on audience). For example: ■ Family planning ■ Antenatal care ■ HIV ■ Emergency settings 60 Discussion of case scenarios in small groups 14:45–15:30 Post-rape care (from Sessions 9 and 10) (pick up a coffee in between) 45 Presentations, Questions & Answers 15:30–15: 50 Return to the barriers/fears identified in the Fear in a Hat exercise 20 15:50–16:00 Closing remarks 10 CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 99 Training schedule for health managers Length Session Core content only Optional content Optional: Ministry introduction — 20–30 minutes Orientation and introductions Optional: Pre-training assessment 60 minutes 20 minutes Session 1. Understanding violence against women as a public health problem Optional: Country-level presentations 40 minutes 15 minutes Session 2. Understanding the survivor’s experience and how providers’ values and beliefs affect the care they give Optional: Additional exercises 80 minutes 40–60 minutes Session 3. Guiding principles and overview of the health response to violence against women 30 minutes — Session 7. Know your setting: identify referral networks and understand the legal and policy context (#) Optional: Additional exercise and invited guest 70 minutes 30–60 minutes Session 11. Documenting intimate partner violence and sexual violence 30 minutes — Session 14. Assessing facility readiness (module for health managers) 60 minutes — Session 15. Strengthening service readiness: improving health workforce capacity (module for health managers) 65 minutes 35 minutes Session 16. Strengthening service readiness: improving infrastructure for privacy, ensuring supplies (module for health managers 60 minutes 30 minutes Session 17. Preventing violence against women (supplemental module) — 105 minutes Conclusion Optional: Post-training assessment 20 minutes 20 minutes Closing and certificate ceremony (optional) — 20–30 minutes Total time ~8.5 hours ~5.5–7.25 hours # For these sessions it is useful to have the participation of other sectors (for example, police, legal, protection, social services, NGOs). CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 100 Annex 2. Tips for training Prepare See checklist for preparation, Table 2, page 9. Plan for the size of your group If the group is large, facilitators may need additional help with logistics or arranging smaller groups for the role play activities. Stay on time and on topic It is the facilitator’s role to keep the training on schedule and on topic. Set expectations early for keeping discussion on task and lengthy stories to a minimum. Remember to stay within the allotted time for each session. You will need to move the discussion along and keep it focused. If off-topic questions come up, let participants know when they will be addressed or put them in a “parking lot” to return to before a break, after a break or at the end of the day. Acknowledge that content may cause distress and manage sensitive or difficult situations Acknowledge that there may be some aspects of the content that may be disturbing for participants who have experienced violence in their own lives. Tell the participants that those who feel distressed during the training can leave the room to take a break and return when ready. Provide a list of resources in the community that could support participants who experience distress because of their own experience of violence and make these resources available to participants. If any participants disrupt the session, suggest that there will be an opportunity to address their concerns separately after the training. “Read” the participants During introductions and over the first few sessions, study your audience: ■ Assess which participants may be comfortable in a role play in front of the group – and which ones might be shy and prefer input in a small group or a one-on-one setting. ■ Identify participants who may be more experienced in providing health care for women subjected to violence. ■ Experienced participants may be helpful in leading role plays and providing examples. ■ You may be able to call on them to start discussion if needed. Engage participants To engage as many different participants as possible, ensure that you give different people chances to speak. Be careful not to over-rely on the experienced participants; instead, encourage everyone to participate. Get moving! ■ Moving around the room for group activities can help energize participants and maintain momentum over a multi-day training. ■ Suggestions for movement are embedded in sessions. Use your judgement and sense of the audience to determine when and how many to incorporate. ■ Use energizers throughout when participants are low in energy, especially immediately after lunch. CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 101 Create an option for anonymous questions Place a hat, box or bag somewhere in the room where participants can leave written questions. Address the new questions at the end of each day or the following morning. This ensures that participants can still ask questions even if they do not want to ask them in front of the group. Keep key resources handy The guiding documents for this training are the 2014 WHO Health care for women subjected to intimate partner violence or sexual violence: a clinical handbook, the 2017 health systems manual, Strengthening health systems to respond to women subjected to intimate partner violence or sexual violence, and the 2017 Responding to children and adolescents who have been sexually abused (see Annex 3). There may also be a national version of the clinical handbook or protocols or standard operating procedures (SOP). Keep all of these close at hand for reference. CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 102 Annex 3. Reading materials and handouts This table lists, by session, the resource materials to be printed or distributed electronically to training participants, and also the facilitator’s printed instructions. ■ Provide the reading materials either on paper or electronically, on a USB stick, as the table suggests. Ask participants to read the clinical handbook as well as the national protocol/guideline/SOP to prepare for the training. The other resources are for additional reference or reading. ■ The handouts are designed for participants to keep as reference materials after the training. They can be distributed electronically on USB sticks for each participant. Printed copies should be made available to participants who cannot use USB sticks. ■ Exercises should be printed in advance with enough copies for all participants. They may require adaptation or translation prior to the training. ■ Materials designated “Facilitator’s resources” should be printed for the facilitator’s use but not distributed to participants. ■ Be sure to leave enough time to assemble participants’ materials. Session Materials and supplemental reading Print or obtain print copies Copy for facilitator only Copy to USB stick All Resource: WHO clinical handbook on health care for women subjected to intimate partner violence or sexual violence (2014) ✔ ✔ Resource: Any national guideline, protocol, SOP or policy documents pertaining to the health response to violence against women ✔ ✔ Resource: Strengthening health systems to respond to women subjected to intimate partner violence or sexual violence: a manual for health managers (2017) ✔ Resource: Responding to children and adolescents who have been sexually abused: WHO clinical guidelines (2017) ✔ PowerPoint materials (slides for all sessions in PDF) ✔ Orientation and introductions Pre-training questionnaire (optional) ✔ 1 Participant handout: Violence against women: Global picture/health response ✔ ✔ Participant handout: Addressing provider barriers to responding to violence against women ✔ ✔ Video: Strengthening health systems response to violence against women (https://www.youtube. com/watch?v=Qc_GHITvTmI) ✔ CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 103 Session Materials and supplemental reading Print or obtain print copies Copy for facilitator only Copy to USB stick 2 Facilitator resource: Exercise 2.1, Option A: Myth or Fact? ✔ Facilitator resource: Exercise 2.1, Option B: Voting with Your Feet ✔ Exercise 2.2, Option A: Blanketed by Blame: Character cards ✔ Exercise 2.2, Option B: In Her Shoes Facilitator resource available at: http:// raisingvoices.org/innovation/creating- methodologies/in-her-shoes/ ✔ Exercise 2.2, Option B: In Her Shoes Story and station cards available at: http://raisingvoices.org/innovation/creating- methodologies/in-her-shoes/ ✔ Participant handout: Why don’t women leave? ✔ ✔ Participant handout: Barriers to care-seeking ✔ ✔ 3 Participant handout: Poster or small pocket card summarizing LIVES (first-line support) ✔ ✔ 4 Participant handout: Active listening principles ✔ ✔ 5 Exercise 5.1, Option A: Role play on identification of intimate partner violence ✔ Exercise 5.1, Option B: Case reviews on identification of intimate partner violence ✔ Participant handout: Asking about violence ✔ ✔ 6 Exercise 6.1: Role play to practise LIV(ES), part 1 ✔ Video demonstrating identification of violence and LIV elements of LIVES, followed by guided discussion (https://youtu.be/Hu06nVCzih0, minutes 8:40 to 14:20 and 14:47 to 20:36) (30 minutes) ✔ 6 Participant handout: Communication skills and pathways ✔ ✔ Participant handout: Health-care providers’ common questions ✔ ✔ 7 Exercise 7.1: The Web of Referrals – character cards ✔ Exercise 7.2: Drawing the ideal referral pathway – template (job aid 8.1 in the health manager’s manual, page 91) ✔ 8 Exercise 8.1: Role play scenarios (LIV)ES, part 2 ✔ CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 104 Session Materials and supplemental reading Print or obtain print copies Copy for facilitator only Copy to USB stick 9 Participant handout: Responding to children and adolescents who have been sexually abused: WHO clinical guidelines ✔ Participant handout: Preparing to gather the story ✔ ✔ Participant handout: Special considerations for medico-legal services for child victims ✔ ✔ Participant handout: Forensic medical examination ✔ ✔ Participant handout: Medico-legal evidence in sexual violence ✔ ✔ 9 USB key or download: clinical management of rape – e-learning (Step 3, history-taking case study) (http://apps.who.int/iris/bitstream/handle/ 10665/44190/CMoR_CDDownloadMultilingual Version.zip?sequence=2&isAllowed=y) ✔ ✔ Exercise 9.1: Role play on history-taking scenarios ✔ Exercise 9.1: Sample history and examination form (from clinical handbook, pages 91–92) ✔ 9a USB key or download: Clinical management of rape survivors – e-learning – Step 4 (Collecting forensic evidence) (https://www. who.int/reproductivehealth/publications/ emergencies/9789241598576/en/) ✔ Exercise 9a.1: Scenarios and a table for recording responses ✔ 10 Exercise 10.1: Case studies on treatment for sexual assault (includes template with blank tables) ✔ 12 Video showing how to assess risk for depression (https://www.youtube.com/watch?v=hgNAySuI sjY&index=2&list=PLU4ieskOli8GicaEnDweSQ6- yaGxhes5v&t=0s) ✔ ✔ 13 Exercise 13.1: Case reviews in family planning and HIV settings ✔ Participant handout: Pros and cons of contraceptive methods in the context of violence ✔ ✔ Participant handout: HIV disclosure counselling in the context of violence ✔ ✔ CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 105 Session Materials and supplemental reading Print or obtain print copies Copy for facilitator only Copy to USB stick 14 Gender-based violence quality assurance tool (https://www.aidsdatahub.org/resource/gender- based-violence-quality-assurance-tool) ✔ Worksheet for assessing facility readiness, identifying barriers and solutions ✔ ✔ 15 Exercise 15.1 worksheet: Assigning roles and responsibilities, Job aid 4.1, pages 38–39 of health manager’s manual ✔ Exercise 15.2 worksheet: Considerations for a training plan, Job aid 4.2, pages 41–43 of health manager’s manual ✔ ✔ 16 Exercise 16.1: Case description of 2 patients ✔ ✔ Exercise 16.1: Template for patient flow mapping printed on A3 ✔ ✔ Exercise 16.2 worksheet: Checklist of equipment, medicines and other supplies printed on A3, Job aid 5.2, page 56 of health manager’s manual ✔ ✔ 17 Participant handout: Assess the risk and protective factors ✔ Participant handout: Examples of health promotion messages addressing violence against women ✔ (https://bit.ly/3Dkysgk) ✔ ✔ Video showing RESPECT rap video (https://youtu.be/kYu3mFjuhTM) ✔ Conclusion Training feedback (evaluation) form ✔ Post-training questionnaire (optional) ✔ CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 106 Annex 4. Supplies checklist … Laptop with PowerPoint software and VLC or other media player … Flip charts … Markers – pens that write on flip charts … Pens … Notebooks for note-taking … Coloured post-it notes … Coloured index cards … Tape or something else to stick flip charts to the walls … Hat or box of bowl (for Fear and Motivations in a Hat exercise) … 11 shawls or newspaper sheets (for Blanketed by Blame exercise) … 2–3 balls of coloured yarn (for referral exercise) … Reading materials, handouts and other learning materials for participants (see Annex 3) CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 107 Annex 5. Providing feedback: responding to questions and role plays Responding to questions ■ Answer questions briefly and, where appropriate, turn the question to the rest of the learners for input. This works particularly well for feedback on role plays or handling difficult situations. ■ Refer participants to written materials for references and/or further clarification. ■ If the question will be answered in a future session, let learners know when it will come up. ■ After a question has been discussed, ask the participant if the question was answered. If time is constrained, you may need to follow up with the participant during a break if they need more information or discussion. ■ Incorporate core principles in your answers where possible. Core principles are most useful for responding to questions that include trusting women’s safety decisions, self-determination and listening to patients. For example, the principle of self-determination means that we let the patient determine when or how she will disclose violence. ■ Ask the participants to read the frequently asked questions in the clinical handbook (pages 34–37) and see if some of their questions are answered. ■ There may be participants who express helplessness or frustration about structural or systemic issues that are beyond their control, such as constraints on resources available for survivors of violence or communication systems that they feel could put survivors at risk. ■ Acknowledge the challenging systems within which participants are working. ■ Encourage them to engage their supervisors and managers and refer them to the health manager’s manual on strengthening health systems as a guide for improving system-level constraints. ■ Some questions may be beyond the scope of the training. ■ Remind learners that the training is focused on first-line support, clinical care, documentation and referrals. ■ Remind participants that addressing violence against women requires a multi-pronged, multisectoral approach and that the health sector has, nonetheless, an important contribution to make. It is not their responsibility to solve all the problems of the survivors. ■ Encourage participants to seek out additional information and make connections with advocates, programmers and service providers from other sectors to create a community of practice and learning. ■ Some questions may indicate participants’ desire to ascertain whether a survivor has indeed experienced violence as she claims. ■ Remind participants that it is for the justice system to establish, based on the evidence, whether the survivor has been subjected to violence or assault. Their role as health-care providers is to provide, without judgement, the health care and first-line support needed and to document, in as much detail as possible, the history (as told by her) and the physical examination findings. CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 108 Role plays Role plays are an essential component of this training and represent opportunities for trainees to practise their skills. These skills are practised in groups of three, taking turns to play the role of the provider, survivor and observer. ■ The observers should observe the interactions and provide constructive feedback on the role play. ■ Feedback should be given in a structured manner, based on the instructions for role plays that the facilitator should provide. ■ Facilitators should circulate and provide constructive suggestions where needed. ■ Invite one group to demonstrate their role play in front of the entire group after determining whether they are comfortable or not. ■ Ask participants to remain constructive when providing feedback and assure the people who are demonstrating the role play that this is not a judgement of their performance. ■ The facilitator can also demonstrate to the entire group a role play of an effective way of practising LIVES and/or show a video that models the correct behaviours. Note: when having participants do role plays in front of the group, choose as provider those most likely to demonstrate a comprehensive response according to the steps taught, as this will be seen as an example of how it should be done. Providing feedback on role plays ■ Remember, your participants may be new to LIVES and discussing violence against women. Your role is to encourage them and provide examples and feedback to help them improve. ■ Be sure to emphasize positive feedback and point out what was done well. ■ Areas that need adjustment can be referred to as “opportunities for improvement”. ■ Directly correct anything that may be harmful to patients, such as victim-blaming. Structure for providing feedback on role plays in small groups or within the large group ■ Comment first on 1–2 areas that worked well (remember to include verbal and non-verbal communication; link to guiding principles if possible). ■ Ask those doing the role play what areas were difficult. ■ Provide suggestions for improvement. ■ Invite others in the group to provide suggestions as to how the difficult area could be handled. ■ Provide any last facilitator comment or recommendation. ■ Thank the presenters. CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 109 Annex 6. Certificate distribution or ceremony (optional) Signed completion certificates can be a lasting reminder of the lessons learned in the training and can be an incentive to put the learning into practice. If printed and signed completion certificates will be provided to participants, allow sufficient time to prepare and sign the certificates. Individual recognition through a certificate ceremony can inspire training participants to become champions and affirm their important role in providing health care to survivors of violence. Present the certificates individually, calling each participant to the front of the room for presentation by a facilitator and a photo (20–30 minutes). If time is limited, consider distributing certificates as participants leave or mailing certificates. CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 110 Annex 7. Tools for monitoring and evaluation Evaluation allows facilitators to understand whether the training objectives have been met. Evaluation tools can also be used to assess needs for refresher training. The evaluation tools include: Participant pre- and post-training questionnaires ■ Evaluate trainees’ knowledge, attitudes and skills/competencies pre- and post-training ■ Assess demographics, practice characteristics and training background ■ Can be administered: ■ immediately before and after the training (recommended) AND ■ at regular intervals (3–6 months) thereafter, to assess the durability of lessons learned and identify needs for ongoing support. Implementation documentation ■ Documents the setting, dates of implementation, number and nature of participants, length of training, adaptations to the training materials and recommendations for adaptations to the training ■ Is completed by the facilitator ■ Can be completed after the training as part of documentation and ongoing quality improvement for the training. Training feedback/evaluation form ■ To be administered at the end of the training. ■ Provides an overall assessment of the training, identifying which sessions worked and which ones need to be improved. CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 111 Annex 8. Supplemental exercises The following exercises are supplemental to reinforce the primary objectives of the training. Facilitators should consider time and group interests when considering where and how to incorporate these activities. Many of these activities can be useful for encouraging attitudinal change. For example: ■ When sufficient time is available, start the training with (one or more of ) these supplemental sensitization activities below to allow the participants to further understand the underlying causes of violence and how response behaviour may impact survivors. ■ If not possible at the start, reconvene participants 4–6 weeks after the training and complete one of the supplemental activities below. ■ Incorporate a supplemental activity at a regularly scheduled meeting. Learning objectives and competencies Objective 1: Demonstrate general knowledge of violence against women as a public health problem. Competencies: ■ Articulate the pervasiveness and normalization of violence and how it impacts all individuals. ■ Describe factors in society that contribute to the perpetuation of intimate partner and sexual violence. Objective 2: Demonstrate values and behaviours contributing to safe and supportive services Competency: ■ Demonstrate an awareness of how power differences between people have shaped our lives and experiences. Recommended supplemental exercises The Space Between Us1 This activity creates awareness of how power has shaped our lives and experiences and exposes participants to the terms “gender equality” and “gender equity”. 60 minutes The Factors that Perpetuate Violence This activity identifies the community and social norms and roles that contribute to violence. 25 minutes Additional supplemental activities Personal Beliefs and Different Listening Experiences This activity is designed for participants to understand how their own assumptions can influence listening and the response provided. 45 minutes Persons and Things This activity involves participants acting as persons commanding things (objects) to do things and reflecting on how it feels to be a person in charge of a thing and vice versa. It aims to increase awareness about the existence of power in relationships and its impact on individuals and relationships. 45 minutes Violence in Our Daily Life This activity explores the pervasiveness and normalization of violence and how it impacts all individuals. 40 minutes Root Causes This activity allows for participants to explore the root causes of violence against women. 70 minutes 1 From Raising Voices Sasa!: http://raisingvoices.org/wp-content/uploads/2013/03/downloads/Sasa/SASA_Activist_Kit/START/Training/ Start.Training.DeepKnowModule.pdf. CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 112 Annex 9. Overview of handouts and resources for exercises* Session Handout 1 Violence against women global picture health response 1 Addressing provider barriers to assessment of violence against women 1 Why does the health care provider response matter? 2 Why don’t women leave 2 Barriers to seeking care 3 Poster/small pocket card summarising LIVES 4 Active listening principles 5 Asking about violence 6 Communication skills and pathway 6 Health-care providers’ common questions 9 Good practice for history taking, physical examination and documentation of findings of children and adolescents who have been sexually abused 9 Preparing to gather the story 9 Special considerations for medico-legal services for child victims 9 The forensic medical examination 9 Medico-legal evidence in sexual violence 13 Pros and Cons of contraceptive methods in the context of violence 13 HIV disclosure counselling in the context of violence 17 Examples of health promotion messages Session Exercise number Exercise Time Facilitator resources and participant handouts 0 1 Fear and motivations in a hat 30 min ■ See facilitator’s guide: pp 15–16 2 2.1 A Myth or Fact 15 min ■ Facilitator resource 2 2.1 B Voting with your feet 30 min ■ Facilitator resource and 2 signs 2 2.2 A Blanketed by blame 45 min ■ See facilitator’s guide: pp 23–24 ■ Participant handout: character cards 2 2.2 B In her shoes 75 min ■ Facilitator resource 4 4.1 Active listening 30 min ■ See facilitator’s guide: pp 33–34 5 5.1 A A Role play on identification of intimate partner violence 60 min ■ Participant handout: Role play scenarios on IPV identification 5 5.1 B Case reviews on identification of intimate partner violence 30 min ■ Participant handout: case reviews on IPV identification Overview of resources for exercises Overview of handouts CARING FOR WOMEN SUBJECTED TO VIOLENCE: A WHO TRAINING CURRICULUM FOR HEALTH CARE PROVIDERS. REVISED EDITION, 2021 113 Session Exercise number Exercise Time Facilitator resources and participant handouts 6 6.1 Role play scenarios on LIV(ES), part one 60 min ■ See facilitators’ guide: pp 42–43 ■ Participant handout: Role play scenarios 7 7.1 The web of referrals 30 min ■ See facilitator’s guide: pp 46 ■ Participant handout: Character cards 7 7.2 Drawing the ideal referral pathway 30 min ■ See facilitator’s guide: pp 47 ■ Participant handout: template 8 8.1 Role play scenarios on (LIV)ES, part two 60 min ■ Facilitator instructions: see facilitator’s guide, pp 51–52 ■ Participant handout: Role play scenarios 9 9.1 Role play on history-taking 45 min ■ Participant handout: Role play scenarios ■ Participant handout: Sample history and examination form 9a 9a.1 Decision-making on forensic evidence collection 30 min ■ Participant handout: Scenarios and table to record responses 10 10.1 Case studies on treatment after sexual assault 30 min ■ Participant handout: Case studies including template 12 12.1a Stress reduction exercise: slow breathing technique 10 min ■ See facilitator’s guide: pp 68 12 12.1b Stress reduction exercise: Progressive muscle relaxation technique 10 min ■ See facilitator’s guide: pp 68–69 12 12.2 Role play on problem-solving skills 15 min ■ See facilitator’s guide: pp 69 13 13.1 Case reviews in family planning and HIV settings 30 min ■ Participant handout: case reviews in family planning and HIV settings 14 14.1 Assessing facility readiness, identifying barriers and solutions 45 min ■ Participant handout: Worksheet for assessing facility assessment, barriers and solutions 15 15.1 Selecting staff members for training and assigning roles and responsibilities 35 min ■ Participant handout: Worksheet for assigning roles and responsibilities 15 15.1a Prioritizing who will be trained in what 15 min See facilitator’s guide: pp 79 15 15.2 Considerations for a training plan 35 min ■ Participant handout: Worksheet for a training plan 15 15.3 Providing mentoring 15 min See facilitator’s guide: pp 80 16 16.1 Patient flow mapping to assess infrastructure needs for privacy 45 min ■ Participant handout: Case scenarios and patient flow mapping template 16 16.1a Improving privacy in facilities 15 min See facilitator’s guide: pp 84 16 16.2 Equipment, medicine and other supplies 30 min ■ Participant handout: checklist of equipment, medicine and other supplies 17 17.1 Lifeline and problem tree; identifying risks and protective factors 75 min See facilitator’s guide: pp 88 17 17.2 Solutions tree – health promotion and 15 min See facilitator’s guide: pp 89 * All these materials are available from: www.who.int/reproductivehealth/publications/caring-for-women-subject-to-violence/en/ For more information, please contact: Department of Sexual and Reproductive Health and Research World Health Organization Avenue Appia 20, CH-1211 Geneva 27, Switzerland Email: srhavp@who.int https://www.who.int/health-topics/violence-against-women#tab=tab_1 ISBN 978 92 4 003980 3

Cuidando de mulheres em situação de violência: um currículo de treinamento da OMS para profissionais de saúde. Edição revisada, 2021.

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A tradução para português da publicação “Caring for women subjected to violence: a WHO curriculum for training health-care providers, Revised edition, 2021”, da Organização Mundial de Saúde foi realizada no âmbito do projeto interinstitucional entre Universidade Federal do Paraná – Departamento de Saúde Coletiva (UFPR), Universidade Estadual do Oeste do Paraná – Departamento de Enfermagem (UNIOESTE) e Universidade de São Paulo – Departamento de Medicina Preventiva (USP), Brasil.

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O68c Cuidando de mulheres em situação de violência : um currículo de treinamento da OMS para profissionais de saúde. Edição revisada, 2021 / Organização Mundial da Saúde. – 1. ed. – Rio de Janeiro, RJ : Autografia, 2025.

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1. Saúde da mulher. 2. Violência contra a mulher – Prevenção e controle. 3. Profissionais de saúde – Capacitação. I. Título.

CDD 362.83

Elaborado por Maurício Amormino Júnior – CRB6/2422

Publicado pela Organização Mundial da Saúde em 2021

Caring for women subjected to violence: A WHO training curriculum for health care providers. Revised edition, 2021

© Organização Mundial da Saúde 2021

Alguns direitos reservados. Esta obra está disponível sob a licença Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo/ ).

Esta tradução não foi criada pela Organização Mundial da Saúde (OMS). A OMS não se responsabiliza pelo conteúdo ou pela exatidão desta tradução. A edição original em inglês, Caring for women subjected to violence: a WHO curriculum for training health-care providers, revised edition, 2021. Geneva: World Health Organization; 2021. Licença: CC BY-NC-SA 3.0 IGO será a edição vinculativa e autêntica. A OMS concede direitos de tradução e publicação para uma edição em português brasileiro para a Universidade Federal do Paraná (UFPR) – Departamento de Saúde Coletiva, que é unicamente responsável pela qualidade e fidelidade da versão em português brasileiro. Caso haja inconsistências em relação às versões em inglês e português brasileiro, a versão original em inglês será considerada a versão oficial.

Esta versão traduzida para o português está disponível sob a licença Creative Commons Attribution-NonCommercial-ShareAlike 3.0 licence (CC BY-NC-SA 3.0; https://creativecommons.org/licenses/by-nc-sa/3.0/deed.pt-br )

Cuidando de mulheres em situação de violência: um currículo de treinamento da OMS para profissionais de saúde. Edição revisada, 2021.

1. Violência contra a mulher. 2. Direitos humanos. 3. Serviços de saúde. 4. Saúde Coletiva. 5. Agressões sexuais.

© Universidade Federal do Paraná – Departamento de Saúde Coletiva – UFPR/DSC (2025)

A tradução deste documento foi realizada no âmbito do projeto interinstitucional entre Universidade Federal do Paraná – departamento de Saúde Coletiva (UFPR), Universidade Estadual do Oeste do Paraná – Programa de Pós Graduação – Mestrado em Ensino (UNIOESTE) e Universidade de São Paulo – Departamento de Medicina Preventiva (USP), Brasil.

Equipe de Tradução, adaptação transcultural e revisão da tradução: Prof. Dr. Marcos Claudio Signorelli (UFPR), Mestranda Celeste Reis de Castro Rego Lopes (UNIOESTE), Profª. Drª. Elis Maria Teixeira Palma Priotto (UNIOESTE), Drª Stephanie Pereira (USP), Profª. Drª Ana Flávia Pires Lucas d’Oliveira (USP)

Este projeto contou com apoio financeiro do Programa de Extensão da Educação Superior na Pós-Graduação (PROEXT-PG) da CAPES/UFPR e Programa

de Pós Graduação em Ensino (PPGEN) UNIOESTE - Foz do Iguaçu.

Diagramação: Lucia Quaresma

Sumário

Agradecimentos ���������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 1

Propósito e visão geral ���������������������������������������������������������������������������������������������������������������������������������������������������������������������� 2

Hora de começar ���������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 9

Boas-vindas e comentários iniciais ��������������������������������������������������������������������������������������������������������������������������������������������� 14

Sessão 1. A violência contra mulheres como um problema de saúde pública �������������������������������������������� 18

Sessão 2. A experiência da mulher em situação de violência e como os valores e

crenças dos profissionais de saúde afetam o cuidado prestado ��������������������������������������������������������������������� 21

Sessão 3. Princípios orientadores e visão geral da resposta de saúde à violência

contra mulheres �������������������������������������������������������������������������������������������������������������������������������������������������������������� 30

Sessão 4. Habilidades de comunicação entre profissionais de saúde e a mulher

em situação de violência ���������������������������������������������������������������������������������������������������������������������������������������������� 33

Sessão 5. Quando e como identificar a violência por parceiro íntimo ���������������������������������������������������������� 35

Sessão 6. Acolhimento inicial usando a ANI(MA), parte 1: Atenção ao ouvir, Não

julgar e sim validar, Informar-se ������������������������������������������������������������������������������������������������������������������������������� 40

Sessão 7. Conhecendo seu entorno: identificar redes de encaminhamento e

compreender o contexto jurídico e as políticas públicas ���������������������������������������������������������������������������������� 44

Sessão 8. Acolhimento inicial usando a (ANI)MA, parte 2: Melhorar a segurança e Apoiar ������������������� 49

Sessão 9. Atendimento clínico para mulheres que sofreram agressão sexual/

estupro, parte 1: coleta de relato e exame ������������������������������������������������������������������������������������������������������������ 53

Sessão 9a. Exame forense (complementar) ����������������������������������������������������������������������������������������������������������� 56

Sessão 10. Atendimento clínico para mulheres que sofreram agressão sexual/

estupro, parte 2: tratamento e cuidado������������������������������������������������������������������������������������������������������������������ 60

Sessão 11. Documentando a violência por parceiro íntimo e a violência sexual ��������������������������������������� 63

Sessão 12. Saúde mental e autocuidado para profissionais ���������������������������������������������������������������������������� 65

Sessão 13. Como abordar o planejamento reprodutivo e a comunicação do

diagnóstico de HIV para mulheres em situação de violência (complementar) ������������������������������������������ 70

Sessão 14. Avaliação do nível de preparo de unidades/serviços de saúde

(módulo para gestores de saúde) ������������������������������������������������������������������������������������������������������������������������������ 73

Sessão 15. Fortalecendo o nível de preparo do serviço: melhorando a

capacidade da força de trabalho em saúde (módulo para gestores de saúde) ������������������������������������������� 76

Sessão 16. Fortalecendo o nível de preparo do serviço: melhorando a

infraestrutura para privacidade e garantindo materiais (módulo para gestores de saúde) ����������������� 81

Sessão 17. Prevenção da violência contra mulheres (complementar) ����������������������������������������������������������� 85

Conclusão ��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������90

Referências e leituras complementares ������������������������������������������������������������������������������������������������������������������������92

Anexo 1. Tempo de treinamento e exemplos de programação ������������������������������������������������������������������������������94

Anexo 2. Dicas para treinamentos ���������������������������������������������������������������������������������������������������������������������������������100

Anexo 3. Materiais de leitura e apoio �������������������������������������������������������������������������������������������������������������������������� 102

Anexo 4. Checklist de materiais ������������������������������������������������������������������������������������������������������������������������������������� 107

Anexo 5. Fornecendo feedback: respondendo a perguntas e role plays ����������������������������������������������������������108

Anexo 6. Distribuição de certificados ou cerimônia (opcional) ��������������������������������������������������������������������������� 110

Anexo 7. Ferramentas para monitoramento e avaliação ��������������������������������������������������������������������������������������� 111

Anexo 8. Exercícios complementares ��������������������������������������������������������������������������������������������������������������������������� 112

Anexo 9. Visão geral dos materiais e recursos para exercícios* ��������������������������������������������������������������������������� 114

* Os materiais de apoio (por exemplo, folhas de atividade, recursos para exercícios e apresentação de slides) podem ser acessados aqui: https://www.who.int/publications/i/item/9789240039803

Guia para facilitadores

Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde. 1

Agradecimentos

Este currículo é resultado do trabalho de muitas pessoas ao redor do mundo dedicadas a prevenir e responder a todas as formas de violência contra mulheres e meninas. A OMS gostaria de agradecer a todos que contribuíram e compartilharam seus exercícios de treinamento e experiências, muitos dos quais foram incorporados a este manual.

O currículo foi desenvolvido pelo Departamento de Saúde Sexual e Reprodutiva e Pesquisa (SRH) da OMS (Avni Amin, Claudia García-Moreno e Megin Reijnders) em colaboração com o Escritório Regional da OMS para as Américas/ Organização Pan-Americana da Saúde (Alessandra Guedes e Constanza Hege).

Um rascunho inicial foi desenvolvido em colaboração com a Escola Bloomberg de Saúde Pública do Johns Hopkins e a Universidade de Michigan: Myra Betron, Michele Decker, Nancy Glass, Zaynab Hameeduddin, Jane McKenzie-White, Sophie Morse e Vijay Singh. Versões preliminares do currículo foram testadas com profissionais da saúde nas Bahamas e na Guiana (pela JHU e OPAS), em Mianmar, Namíbia, Paquistão, Uganda e Zâmbia (pela OMS/SRH) e com enfermeiras obstetras em Timor Leste, por Angela Taft e Kayli Wild.

O SRH também utilizou os materiais em um treinamento de formadores em Genebra em julho de 2018 e em um treinamento virtual de gestores de saúde de 12 países do leste e sul da África em 2020.

A OMS/SRH agradece aos consultores e estagiários que apoiaram a organização inicial do desenvolvimento do currículo, Floriza Gennari, Erin Hartman e Thais de Rezende.

A OMS/SRH expressa sua gratidão aos membros do conselho consultivo do currículo por todas as suas contribuições e sugestões ao longo do processo de desenvolvimento e revisão dos rascunhos: Kiran Bhatia, Jan Coles, Anne Catherine Deleon, Kelsey Hegerty, Lisa James, Ana Flavia Lucas d’Oliveira, Grace Mallya, Soroja Pande, Lourdesita Sobreyega- Chan, Jinan Usta e Silvie Lo Fo Wong.

O SRH também gostaria de agradecer às seguintes pessoas pela revisão dos rascunhos do currículo: Anna Baptista, Jennifer Breads, Jovita Ortiz Contreras, Claire Mathonsi, Rose Olson, Caroline Rodriguez, Sarah Siebert, Angela Taft, Kusum Thapa e Kayli Wild.

Sara Johnson e Ward Rinehart desenvolveram a estrutura e ajudaram a escrever as instruções dos exercícios contidos no currículo.

2Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde.

Propósito e visão geral

A violência contra mulheres, incluindo a violência por parceiro íntimo e a violência sexual, é um fenômeno global generalizado e causa problemas sérios de saúde física e mental. Portanto, ela é uma questão de saúde pública que precisa ser abordada de modo coordenado por profissionais e sistemas de saúde em todo o mundo. A Organização Mundial da Saúde (OMS) desenvolveu diretrizes para o setor de saúde: Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines (2013) e um Manual Clínico complementar: Health care for women subjected to intimate partner violence or sexual violence: a clinical handbook (2014), chamado aqui de “Manual Clínico”. Este currículo de serviço, baseado nesses documentos, oferece a profissionais de saúde o conhecimento e as habilidades básicas para incorporar as recomendações da OMS à prática clínica. Treinar os profissionais é fundamental para melhorar a resposta do sistema de saúde à violência contra mulheres.

Este currículo foi elaborado para fornecer aos profissionais de saúde, especialmente em países de baixa e média renda, uma base lidar com a violência doméstica/por parceiro íntimo e a violência sexual

contra mulheres. O currículo busca desenvolver habilidades e abordar as atitudes dos profissionais de saúde em relação às mulheres em situação de violência. Os participantes aprenderão a realizar atendimentos clínicos centrados na mulher, incluindo identificar mulheres que sofrem violência, fazer o acolhimento inicial através da abordagem ANIMA (Atenção ao ouvir; Não julgar e sim validar; Informar- se; Melhorar a segurança; Apoiar), fornecendo cuidados clínicos essenciais para mulheres em situação de violência e identificando recursos de apoio locais. Eles aprenderão a refletir sobre suas próprias atitudes e a entender a

experiência das mulheres em situação de violência. O currículo tem como foco a comunicação com empatia e compaixão entre profissional e a paciente.

Este currículo é baseado no Manual Clínico da OMS. Aconselha-se que participantes e facilitadores tenham o manual à mão para consultar ao longo do treinamento.

O treinamento é um componente importante de uma resposta ampla do sistema de saúde à violência contra mulheres. Gestores de serviços e formuladores de políticas públicas de saúde também são responsáveis por planejar, coordenar e gerir recursos humanos; estabelecer políticas e protocolos; e monitorar e avaliar o cuidado prestado às mulheres em situação de violência. Quatro novos módulos foram adicionados à edição revisada de 2021, e o conteúdo anterior continua inalterado. Três dos novos módulos são especificamente direcionados a gestores de saúde para avaliar e melhorar as instalações, incluindo qualificar a força de trabalho de saúde e a infraestrutura. Há um novo módulo direcionado tanto a gestores quanto a profissionais de saúde quanto. Ele tem como foco melhorar a integração de intervenções de prevenção nos serviços de saúde existentes. Aconselha-se que gestores e formuladores de políticas públicas consultem Strengthening health systems to respond to women subjected to intimate partner violence or sexual violence: a manual for health managers (OMS, 2017) para encontrar orientações sobre como melhorar o preparo do sistema de saúde.

As diretrizes clínicas que pautam este treinamento não abordam especificamente crianças, meninas adolescentes (menores de 18 anos) ou homens. No entanto, as ações descritas também podem ser valiosas para essas populações. Elas também se aplicam à violência doméstica de forma mais ampla – ou seja, violência por membros da família que não sejam um parceiro íntimo. Os facilitadores são incentivados a revisar o documento Responding to children and adolescents who have been sexually abused: WHO clinical guidelines (OMS, 2017) para encontrar recomendações sobre como atender crianças e adolescentes.

Acolhimento inicial

A Atenção ao ouvir

N Não julgar e sim validar

I Informar-se

M Melhorar a segurança

A Apoiar

Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde. 3

Para quem é este treinamento?

Este currículo de treinamento foi elaborado principalmente para profissionais de saúde, particularmente médicos, enfermeiros e obstetras. Partes dele também podem ser úteis para outros profissionais de saúde, incluindo psicólogos, assistentes sociais, auxiliares de enfermagem, agentes comunitários de saúde e conselheiros leigos. As sessões 14 a 17 também são voltadas a gestores de saúde.

Aprendizado centrado no participante

Este currículo utiliza uma abordagem centrada no participante, uma abordagem de ensino e treinamento ativa, colaborativa e baseada em investigação. Também conhecido como educação centrada no aprendiz, o aprendizado centrado no participante enfatiza o papel ativo de quem aprende.

Em vez de depender dos facilitadores, o aprendizado centrado no participante incentiva a interação do aprendiz sempre que possível. Os aprendizes participam ativamente no desenvolvimento de conhecimentos e habilidades por

meio de estudos de caso, discussões guiadas, exercícios participativos de reflexão, vídeos e leituras. Esse processo ajuda na reflexão crítica, no engajamento emocional, no desenvolvimento de habilidades e na capacidade de colocar o conhecimento em prática.

Treinamento baseado em competências

Este currículo baseado em competências permite o desenvolvimento do conhecimento e das habilidades para fornecer cuidados abrangentes e de alta qualidade a mulheres em situação de violência por parceiro íntimo ou violência sexual. Cada sessão é voltada a um dos quatro objetivos (ver quadro), além de promover competências únicas. A Tabela 1 apresenta os títulos e competências das sessões de treinamento. Os objetivos e capacidades deste treinamento foram definidos por meio de um processo de revisão por especialistas.

Tabela 1. Sessões, objetivos e competências

Nº Sessão, objetivo, competências

1 A violência contra mulheres como um problema de saúde pública

Objetivo 1. Demonstrar conhecimento geral sobre a violência contra mulheres como um problema de saúde pública.

Competências:

� Conhecer a epidemiologia das diferentes formas de violência contra mulheres em níveis global e local.

� Conhecer as consequências da violência contra mulheres sobre a saúde.

� Entender o papel e as limitações de profissional de saúde no manejo da violência contra mulheres.

� Saber sobre as diretrizes clínicas e de políticas públicas e o Manual Clínico da OMS sobre respostas à violência por parceiro íntimo e à violência sexual contra as mulheres.

Objetivo deste treinamento

Promover a compreensão e desenvolver as habilidades básicas para implementar as recomendações das diretrizes clínicas de políticas públicas da OMS e do Manual Clínico para responder à violência por parceiro íntimo e violência sexual contra mulheres.

Os quatro objetivos do treinamento

1. Demonstrar conhecimento geral sobre violência contra mulheres como um problema de saúde pública.

2. Demonstrar comportamentos e compreender valores que contribuem para serviços seguros e acolhedores.

3. Demonstrar habilidades clínicas apropriadas à profissão e conhecimento especializado para responder à violência contra mulheres.

4. Demonstrar conhecimento sobre como acessar recursos e apoio para pacientes e para si mesmo(a)

4Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde.

Nº Sessão, objetivo, competências

2 A experiência da mulher em situação de violência e como os valores e crenças dos profissionais de saúde afetam o cuidado prestado

Objetivo 2. Demonstrar comportamentos e compreender valores que contribuem para serviços seguros e acolhedores

Competências:

� Demonstrar autoconsciência sobre suas crenças, suposições, possíveis preconceitos e respostas emocionais que podem afetar as interações com mulheres em situação de violência.

� Entender as circunstâncias e as barreiras que as mulheres que sofrem violência encontram ao buscar apoio.

� Reconhecer a importância de ter empatia com as mulheres em situação de violência.

3 Princípios orientadores e visão geral da resposta de saúde à violência contra mulheres

Objetivo 2: Demonstrar comportamentos e compreender valores que contribuem para serviços seguros e acolhedores

� Conhecer os princípios orientadores para prestar cuidado centrado na mulher de forma culturalmente adequada.

� Entender como colocar em prática os princípios orientadores do atendimento centrado na mulher.

4 Habilidades de comunicação entre profissionais de saúde e a mulher em situação de violência

Objetivo 2: Demonstrar comportamentos e entender os valores que contribuem para serviços seguros e acolhedores

Competência:

� Estabelecer uma comunicação empática e eficaz com pacientes/mulheres em situação de violência.

5 Quando e como identificar a violência por parceiro íntimo

Objetivo 3: Demonstrar habilidades clínicas apropriadas à profissão e conhecimento especializado para responder à violência contra mulheres.

Competências:

� Entender os padrões mínimos que precisam ser atendidos para buscar informações e responder adequadamente à violência contra mulheres.

� Reconhecer os sinais e sintomas que sugerem violência por parceiro íntimo.

� Compreender quando e como perguntar sobre violência por parceiro íntimo.

� Demonstrar maneiras apropriadas de perguntar sobre violência por parceiro íntimo.

6 Acolhimento inicial usando a ANI(MA), parte 1: Atenção ao ouvir, Não julgar e sim validar, Informar-se

Objetivo 3: Demonstrar habilidades clínicas apropriadas à profissão e conhecimento especializado para responder à violência contra mulheres.

Competências:

� Conhecer o conteúdo do acolhimento inicial (ANIMA).

� Demonstrar habilidades relacionadas aos três primeiros elementos (Atenção ao ouvir; Não julgar e sim validar; Informar-se) do acolhimento inicial a mulheres em situação de violência que relatam abusos.

7 Conhecendo seu entorno: identificar redes de encaminhamento e compreender o contexto jurídico e as políticas públicas

Objetivo 4: Demonstrar conhecimento sobre como acessar recursos e apoio para pacientes e para si

Competências:

� Compreender o papel de outros serviços no cuidado de mulheres em situação de violência.

� Saber quais recursos estão disponíveis na comunidade.

� Conhecer o contexto jurídico e de políticas públicas, incluindo as obrigações legais dos profissionais de saúde, no que diz respeito à resposta local e nacional à violência contra mulheres

Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde. 5

Nº Sessão, objetivo, competências

8 Acolhimento inicial usando a (ANI)MA, parte 2: Melhorar a segurança e Apoiar

Objetivo 3: Demonstrar habilidades clínicas apropriadas à profissão e conhecimento especializado para responder à violência contra mulheres.

Objetivo 4: Demonstrar conhecimento sobre como acessar recursos e apoio para pacientes e para si

Competências:

� Demonstrar habilidades para avaliar a segurança e riscos imediatos para apoiar o planejamento de segurança.

� Saber quais recursos estão disponíveis na comunidade.

� Saber como colaborar com parceiros para encaminhar e ajudar as mulheres em situação de violência a acessar outros serviços.

� Demonstrar habilidades para encaminhar de forma acolhedora.

9 Atendimento clínico para mulheres que sofreram agressão sexual/estupro, parte 1: coleta de relato e exame

Objetivo 3: Demonstrar habilidades clínicas apropriadas à profissão e conhecimento especializado para responder à violência contra mulheres.

Competências:

� Demonstrar habilidades para coletar um histórico.

� Saber como examinar uma mulher que sofreu violência sexual, incluindo estupro e outras formas de abuso.

� Saber quando coletar evidências forenses e como apoiar ou facilitar essa coleta.

9a Exame forense (complementar)

Objetivo 3: Demonstrar habilidades clínicas apropriadas à profissão e conhecimento especializado para responder à violência contra mulheres.

Competência:

� Saber quando e como coletar evidências forenses.

10 Sessão 10. Atendimento clínico para mulheres que sofreram agressão sexual/estupro, parte 2: tratamento e cuidado

Objetivo 3: Demonstrar habilidades clínicas apropriadas à profissão e conhecimento especializado para responder à violência contra mulheres.

Competência:

� Saber como fornecer tratamento/cuidados apropriados para mulheres que sofreram violência sexual, incluindo estupro e outras formas de abuso.

11 Documentando a violência por parceiro íntimo e a violência sexual

Objetivo 3: Demonstrar habilidades clínicas apropriadas à profissão e conhecimento especializado para responder à violência contra mulheres.

Competência:

� Saber como documentar violência contra mulheres de forma segura e confidencial.

12 Saúde mental e autocuidado para profissionais

Objetivo 3: Demonstrar habilidades clínicas apropriadas à profissão e conhecimento especializado para responder à violência contra mulheres.

Objetivo 4: Demonstrar conhecimento sobre como acessar recursos e buscar apoio para pacientes e para si

Competências:

� Saber como oferecer cuidados básicos de saúde mental.

� Saber como acessar e praticar o autocuidado.

6Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde.

Nº Sessão, objetivo, competências

13 Como abordar o planejamento reprodutivo e a comunicação do diagnóstico de HIV para mulheres em situação de violência (complementar)

Objetivo 3: Demonstrar habilidades clínicas apropriadas à profissão e conhecimento especializado para responder à violência contra mulheres.

Competência:

� Demonstrar habilidades na identificação e cuidado de mulheres que viveram situações de violência e que procuram serviços de planejamento reprodutivo ou relacionados a HIV.

14 Avaliação do nível de preparo de unidades/serviços de saúde (módulo para gestores de saúde)

Objetivo 2: Demonstrar comportamentos e entender os valores que contribuem para serviços seguros e acolhedores

Competência:

� Avaliar como melhorar a qualidade do serviço e criar um ambiente propício para a prestação de serviços

15 Melhorar a capacidade da força de trabalho em saúde (módulo para gestores de saúde)

Objetivo 2: Demonstrar comportamentos e entender os valores que contribuem para serviços seguros e acolhedores

Competência:

� Facilitar o treinamento, supervisão e mentoria de profissionais de saúde.

16 Melhorar a infraestrutura para garantir a privacidade e suprimentos (módulo para gestores de saúde)

Objetivo 2: Demonstrar comportamentos e entender os valores que contribuem para serviços seguros e acolhedores

Competência:

� Planejar melhorias na infraestrutura e comprar equipamentos e suprimentos

17 Prevenção da violência contra mulheres (complementar)

Objetivo 3: Demonstrar habilidades clínicas apropriadas à profissão e conhecimento especializado para responder à violência contra mulheres.

Competências:

� Compreender como melhorar os fatores de proteção, minimizar riscos e mitigar consequências prejudiciais da violência contra mulheres

� Conhecer estratégias de prevenção intersetoriais que a saúde pode promover ou articular com outros setores.

� Identificar estratégias de prevenção que podem ser implementadas pelos profissionais/ambientes de saúde

Tempo previsto

O currículo é projetado para ser implementado de forma flexível.As 13 sessões completas são geralmente ministradas em dois dias e meio, e experiências anteriores sugerem que esse é o tempo mínimo exigido. No entanto, se necessário, você pode fazer as sessões 1 a 12 em dois dias. Para abordar o conteúdo principal adequadamente, são necessários no mínimo dois dias contínuos. No entanto, é recomendado que haja tempo adicional para praticar habilidades, especialmente para participantes que estão aprendendo sobre o assunto pela primeira vez. Se só há menos de dois dias disponíveis, você precisará ajustar o conteúdo de acordo com o tempo. Nós sugerimos abordar as sessões 1 a 8 para garantir que a abordagem ANIMA seja totalmente coberta.

São fornecidos exercícios adicionais de desenvolvimento de habilidades, Caso haja mais tempo disponível, é indicado praticar competências de acolhimento inicial, que são

Precisa fazer o treinamento por conta própria?

A melhor forma de usar este guia para facilitadores é em sala de aula ou em grupo. Se você estiver só, identifique pelo menos uma outra pessoa que possa fazer o treinamento com você. Certifique-se de pensar nas questões de reflexão, por conta própria ou com outra pessoa, para obter o máximo da sua experiência de treinamento. Uma versão autoguiada de ensino à distancia (EaD) estará disponível em meados de 2020.

Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde. 7

fundamentais para cuidados clínicos centrados na mulher em situação de violência. Gestores de saúde devem, no mínimo, cobrir as sessões 1 a 7, 11 e 14 a 16 durante um período de 8 a 9 horas.

Alternativamente, o conteúdo principal pode ser abordado em sessões de meio dia, em intervalos regulares durante várias semanas ou meses. Esta abordagem em doses baixas e frequência alta foi eficaz para o treinamento. Nós recomendamos um mínimo de 12 a 14 horas, mas se houver menos tempo disponível, ainda é possível cobrir muitos conteúdos mantendo o foco nas habilidades relacionadas ao acolhimento inicial. Em alguns casos, as sessões foram repetidas seis meses depois, como parte de uma atualização. Se necessário, algumas atividades de desenvolvimento de habilidades podem ser feitas em sessões de meio dia ou de um dia inteiro.

O Anexo 1 mostra o tempo sugerido de cada sessão, com e sem conteúdo complementar. Essa programação pode variar de acordo com o contexto e as preferências locais. Se preferir, pode ser dedicado mais tempo às sessões que envolvem role play, incluindo as sessões 6 e 8. Deve-se planejar o espaçamento e entrega dos conteúdos para garantir que os participantes pratiquem e dominem novas habilidades antes de aprender as novas.

O aprendizado é um processo contínuo. Sessões de atualização em intervalos regulares (por exemplo, anualmente) ajudará profissionais a consolidar e atualizar seus conhecimentos e habilidades.

Quem deve fazer o treinamento?

O treinamento é projetado para um ambiente coletivo, para aproveitar a experiência do grupo para reflexão crítica e apoio para adaptação e implementação de conteúdo ao contexto local e à rede de serviços. Idealmente, este treinamento deve ser feito com grupos de diferentes tipos de profissionais de saúde da mesma unidade – médicos(as), enfermeiros(as)/ obstetras, pessoas com responsabilidades administrativas/de supervisão). Diferentes profissionais de saúde têm diferentes funções e responsabilidades na prestação de cuidados; portanto, precisam aprender a se comunicar e trabalhar em equipe para oferecer cuidados de qualidade. As sessões 1 a 7 e 11 também devem ser conduzidas com gestores de saúde

do mesmo serviço. Alguns treinamentos também já incluíram policiais e profissionais de outros setores.

A abordagem participativa é mais eficaz com pequenos grupos. O ideal é treinar 20 a 30 participantes por vez, para permitir tempo adequado para discussões e atividades interativas. No entanto, o mesmo conteúdo pode ser ministrado a um grupo maior.

Participantes de outros setores

Embora uma grande parte deste treinamento seja projetada especificamente para profissionais de saúde, existem sessões em que pode ser particularmente útil convidar participantes de outros setores, como polícia, justiça, assistência social e organizações que trabalham com comunidades. Um treinamento intersetorial pode ajudar a garantir que todos os participantes compartilhem uma compreensão do que é necessário para atender às necessidades de saúde das mulheres em situação de violência em tempo hábil, o que os profissionais de saúde podem e não podem fazer em relação à assistência médico-legal, como fortalecer a coordenação do cuidado e os encaminhamentos, além de mobilizar as comunidades para apoiar as mulheres em situação de violência.

No Anexo 1 o símbolo # indica uma sessão onde participantes de outros setores podem ser especialmente úteis. Planeje o local de treinamento de forma que permita espaço para mais participantes.

Sobre este guia para facilitadores

Este documento é um guia de facilitadores para o currículo. Ele fornece instruções sobre como implementar este treinamento para otimizar o aprendizado.

� Siga o guia para facilitadores. Este currículo foi desenvolvido com a contribuição de especialistas e facilitadores. Ele passou por vários testes piloto e foi elaborado pensando em facilitadores com variáveis níveis de conhecimento sobre violência contra mulheres e especialistas com diversos graus de conhecimentos sobre como mediar um treinamento. Siga o guia para facilitadores para garantir que os pontos principais sejam ensinados e as recomendações sejam seguidas. Quem tiver experiência na mediação de treinamentos em saúde sobre violência contra mulheres serão capazes

8Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde.

de usar sua experiência para fornecer mais exemplos e insights para quem participa.

� Cada sessão inclui notas de implementação e dicas de mediação para facilitadores. Elas servem para promover atividades ativas e aprendizado centrado nos participantes.

� As notas acompanham muitos dos slides e fornecem informações adicionais para os facilitadores comunicarem os conteúdos.

� As sessões são ordenadas de forma sistemática, desde a construção de uma compreensão do problema e o contexto das mulheres, por meio da construção cumulativa de habilidades. Essa estrutura permite aprofundar e reforçar o uso de conhecimentos e habilidades aprendidas em sessões anteriores.

� As sessões são estruturadas para que os facilitadores possam:

� Ministrar conteúdos e informações importantes com clareza e concisão

� Facilitar a aprendizagem participativa através de uma série de métodos interativos (por exemplo, role plays, demonstrações em vídeo, discussões em grupo, brainstorming)

� Facilitar as reflexões críticas de participantes sobre os principais aprendizados por meio de discussões guiadas

� Resumir as principais mensagens de cada sessão.

Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde. 9

Hora de começar

Quem deve facilitar?

Os melhores facilitadores para este treinamento terão uma combinação do seguinte:

� experiência clínica (profissionais de medicina, enfermagem, psicologia, assistência social)

� experiência na prestação de cuidados de saúde a mulheres em situação de violência

� experiência em treinamento, incluindo liderança interativa de discussões.

É recomendado que haja duas pessoas facilitando o treinamento.

� Os facilitadores devem alternar as funções de liderança e de apoio descritas abaixo para minimizar a fadiga e variar o estilo de apresentação.

� Se possível, pelo menos um(a) cofacilitador(a) deve representar uma unidade de saúde local relevante para apoiar a adesão institucional e permitir a discussão de características locais específicas sobre os materiais, conceitos e recursos.

� Em alguns casos, um(a) único(a) facilitador(a) experiente pode mediar todo o treinamento. Se houver

outras pessoas experientes no grupo, elas podem ser convidadas para apoiar.

Papel do(a) facilitador(a) principal

� Liderar apresentações de conteúdo e discussões

� Circular pela sala durante o trabalho em grupo para monitorar e dar feedback.

Papel do facilitador de apoio

� Monitorar o tempo

� Circular o microfone entre os participantes conforme necessário

� Distribuir exemplos de casos ou materiais escritos quando necessário

� Identificar perguntas do grupo

� Fornecer uma perspectiva adicional sobre questões levantadas no grupo

� Circular pela sala durante o trabalho em grupo para monitorar e dar feedback sobre as atividades.

Preparação para o treinamento

O checklist da Tabela 2 pode ajudar você a se preparar para conduzir o treinamento.

10Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde.

Tabela 2. Checklist de preparação

Conheça quem está no treinamento

� Conheça os participantes. Conhecer o perfil e as responsabilidades profissionais dos participantes e, se forem membros de uma equipe, suas funções dentro dessa equipe.

� Reconheça que alguns aspectos do conteúdo podem ser angustiantes para participantes que sofreram violência (ver dicas no Anexo 3).

Espaço, materiais e equipamentos

� Espaço e equipamentos para reuniões. Se possível, encontre um espaço com recursos audiovisuais. O equipamento pode incluir:

� computador

� projetor

� quadro branco

� microfone com alto-falante/sistema de som adequados caso a sala seja grande.

� Forneça um lugar para ir. Encontre uma sala adicional ou outro espaço onde os participantes possam ir caso não se sintam confortáveis. Pode haver mulheres que sofreram violência participando, e elas podem precisar sair de vez em quando.

� Prepare-se com antecedência. Organize a sala antes do início do curso e verifique os equipamentos.

� Organize as mesas. Prepare a sala com mesas em pequenos grupos (6 a 8 pessoas) para otimizar a participação e as discussões. Não organize a sala em estilo de palestra, com fileiras de cadeiras

Agende e convide as pessoas

� Desenvolva um cronograma. A Tabela 1 propõe a ordem das sessões, mas o cronograma pode ser modificado com base no tempo disponível, na experiência dos participantes e nas atividades complementares.

� Reserve um tempo extra. Se você precisar alterar o cronograma sugerido, revise as instruções do guia para facilitadores para garantir que haja tempo suficiente para discussões, exercícios e pausas.

� Chame os convidados. Considere se, quando e como os convidados serão incluídos como palestrantes ou alunos. Veja a seção sobre convidados, na próxima página.

� Certificados de conclusão? Decida se quer dar certificados de conclusão. Veja a seção sobre distribuição ou cerimônia de certificados (Anexo 6).

Preparação do(a) facilitador(a)

� Materiais. Com antecedência, revise todos os materiais de treinamento, incluindo o guia para facilitadores, slides, notas de slides e materiais de apoio. Este guia para facilitadores detalha pontos importantes de cada sessão. São fornecidas perguntas e pontos de investigação para realizar discussões semiestruturadas. Dê atenção especial ao passo a passo de cada atividade.

� Papéis dos facilitadores. Revise e chegue a um acordo sobre as funções e responsabilidades de cada um em cada sessão.

� Lembretes e dicas essenciais. Revise os lembretes essenciais da Tabela 3 e as dicas para treinamento eficaz do Anexo 2.

Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde. 11

Prepare os materiais � Prepare os materiais de leitura e apoio dos participantes (Anexo 3).

� Entregue o Manual Clínico e outros materiais de referência da OMS com antecedência. Tenha materiais extras prontos para serem distribuídos em cada sessão.

� Imprima os materiais de leitura e folhas de atividade a serem distribuídos. Copie os arquivos a serem distribuídos eletronicamente em um pen drive. Esse pen drive também pode ser usado para documentar os trabalhos em grupo.

� Reúna os materiais (Anexo 4).

Adapte o treinamento para o seu contexto

� Adapte os materiais de treinamento ao contexto local, conforme necessário. Por exemplo, estudos de caso, nomes de personagens nas fichas de história e role plays e recursos visuais devem ser todos adaptados para o contexto local.

� Revise a terminologia no guia para facilitadores e nos slides para garantir que os termos sejam adequados ao contexto local ou modifique conforme necessário.

� Considere adicionar um slide com dados nacionais/regionais sobre violência contra mulheres à Sessão 1 (slide 10).

� Revise o contexto jurídico e de políticas públicas, incluindo leis, políticas e protocolos sobre a violência contra mulheres no ambiente de saúde em que o treinamento está sendo realizado. Eles serão revisados na Sessão 7. Por exemplo,

a. Existe algum protocolo/procedimento operacional padrão para a prestação de serviços?

b. O sistema de informação em saúde tem instrumentos para documentar a violência – por exemplo, fichas de registos da unidade ou formulários de admissão?

c. Quais leis e políticas afetam a confidencialidade, as obrigações de comunicação/ notificação e quem pode prestar cuidados ou realizar procedimentos específicos?

d. Se houver, quais são as circunstâncias sob as quais o aborto pode ser oferecido/ feito?

e. Se houver, quais são as restrições de tratamento baseadas na idade da mulher ou tipo de tratamento?

f. Qual formulário de documentação é usado para casos de violência sexual, incluindo exame forense?

� Mapeie os serviços de apoio (use o gráfico de referência no Manual Clínico como guia).

� Identifique pelo menos um recurso de apoio a ser mencionado no início da sessão de orientação que os participantes poderiam usar se necessário durante o treinamento.

� Considere exibir vídeos e sites que levem em consideração a segurança dos participantes, sejam culturalmente apropriados e não envolvam imagens inadequadas.

Palestrantes e especialistas convidados

Este treinamento pode ser aprimorado com palestrantes ou especialistas convidados, assim como participantes de outros setores.

Palestrantes convidados podem esclarecer tópicos que estão além da experiência dos facilitadores principais. Revise os objetivos de aprendizagem e competências da sessão correspondente com cada palestrante convidado.

Você pode convidar, por exemplo:

� um profissional ou ativista que trabalha com mulheres em situação de violência fornecendo outros tipos de serviços (por exemplo, aconselhamento, apoio jurídico, alojamento) para discutir quais serviços estão disponíveis e como melhorar o encaminhamento (ver Sessão 7)

12Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde.

� um especialista jurídico para falar sobre as leis relativas a violência contra mulheres e as obrigações legais dos profissionais de saúde (ver Sessão 7)

� um representante de uma organização não governamental (ONG) ou organização de mulheres que forneça informações às sobreviventes sobre seus direitos e opções legais (ver Sessão 7)

Formuladores de políticas públicas

Formuladores de políticas públicas ou gestores de saúde seniores podem desempenhar um papel importante, demonstrando compromisso com a resposta à violência contra mulheres no setor da saúde e inspirando os profissionais de saúde.

Formuladores de políticas públicas podem ser convidados para falar sobre políticas, programas e orçamentos relevantes para cuidados de saúde voltados a mulheres em situação de violência.

Tabela 3. Lembretes importantes para treinamentos sobre violência contra mulheres

Autodeterminação: a escolha da mulher é central.

� As preferências e necessidades da paciente/mulher em situação de violência devem guiar a prestação de todos os cuidados. Sempre que possível, relembre os participantes de que confiamos na perspectiva da mulher em situação de violência. É ela quem sabe o que é melhor para si e para a situação dela.

Preste atenção, identifique e responda à culpabilização da mulher em situação de violência.

� Deixe claro que a violência nunca é culpa da mulher.

A terminologia é importante.

� Este currículo usa o termo “mulher em situação de violência” ao invés de “vítima” para indicar que ela tem agência, autonomia e escolha, além de ser uma forma de diminuir o estigma.

E sobre a violência contra homens?

� Muitas vezes, a questão da violência contra homens surge na discussão. Esclareça que:

� Evidências mostram que as formas e a natureza da violência enfrentada por mulheres e homens são diferentes.

� A violência enfrentada por mulheres está enraizada nas desigualdades de poder de gênero e é mais provável que venha de um parceiro íntimo ou membro da família do sexo masculino (ou dentro de outros relacionamentos de confiança) e que seja ocultada.

� Habilidades ensinadas neste treinamento - particularmente a resposta centrada na mulher e o acolhimento inicial - podem ser úteis para acolher homens que tenham sofrido violência.

E as crianças?

� A violência contra crianças e adolescentes também pode surgir na discussão. As sessões 9 e 10, sobre cuidado clínico para agressão sexual, cobrem considerações específicas para crianças e adolescentes.

Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde. 13

Sessões

14Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde.

Boas-vindas e comentários iniciais

Preparação e informações gerais

Duração da sessão 60–80 minutos

Técnicas de treinamento

Exercício: Medo e motivações em um chapéu1 (30 minutos)

Materiais do(a) facilitador(a

Cópias do questionário pré-treinamento (opcional)

� Flip chart/folhas grandes de papel

� Chapéu, cumbuca ou cesto (para o exercício “Medo e motivações em um chapéu”)

� Notas adesivas ou fichas para anotações e fita adesiva

� Canetas

Conteúdo da sessão

Pesquisa pré- treinamento (opcional) (20 minutos)

Se estiver usando a pesquisa como parte da avaliação do treinamento, forneça o questionário pré- treinamento para os participantes completarem.

Apresentações (10 minutos)

Apresente-se e diga quem são os outros facilitadores e palestrantes, descrevendo brevemente a experiência de cada um.

Explique que vamos começar pelas apresentações dos participantes e uma breve discussão sobre os objetivos de aprendizagem do treinamento.

Convide os participantes a formar duplas com seus vizinhos. Peça para as duplas se apresentarem aos seus parceiros (seus nomes, o que o nome significa ou representa em sua cultura, sua função e cargo na instituição) em 2 ou 3 minutos. Em grupo, dependendo do número de participantes e do tempo disponível, peça para 3 a 4 duplas apresentarem seus parceiros aos outros participantes (1 minuto por dupla).

Observação: Mesmo que os participantes já se conheçam, este exercício para facilitar as apresentações é útil para quebrar o gelo. Além disso, assim o(a) facilitador(a) tem a chance de conhecer os participantes. Esse é uma exemplo, mas você pode encontrar outras formas criativas de ajudar os participantes a se apresentarem de acordo com o contexto.

1 Adaptado de “Fear in a Hat”, de Kelsey Hegarty.

Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde. 15

Apresente os objetivos de aprendizagem gerais do treinamento (5 minutos)

Como resultado deste treinamento, os participantes serão capazes de (Slide 2):

� Objetivo 1: Demonstrar conhecimento geral sobre a violência contra mulheres como um problema de saúde pública.

� Objetivo 2: Demonstrar comportamentos e compreender valores que contribuem para serviços seguros e acolhedores.

� Objetivo 3: Demonstrar habilidades clínicas apropriadas à profissão e conhecimento especializado para responder à violência contra mulheres.

� Objetivo 4: Demonstrar conhecimento sobre como acessar recursos e apoio para pacientes e para si

Apresentação da programação e da logística (15 minutos)

Visão geral do treinamento (Slide 3)

Revisar a programação.

Informações gerais: Oriente os participantes sobre o espaço de treinamento (por exemplo, onde fica o banheiro, onde há um local quieto/seguro se alguém precisar sair e outras logísticas).

Expectativas: Pergunte aos participantes: “O que vocês esperam do treinamento?”

Escreva as expectativas dos participante em um flip chart ou em um papel grande e coloque-o na frente de todos.

Revise a lista rapidamente para que você possa se referir a ela durante o treinamento. Caso surja algum tópico que não será abordado, decida se ele pode ser incluído dentro da programação planejada ou se precisa de um treinamento adicional separado.

Explique que o formato do treinamento é uma mistura de métodos didáticos e participativos.

Reconheça a presença de mulheres em situação de violência e peça que todos ajam com sensibilidade.

� Por exemplo: “Quero lembrar a todos que alguns de nós podemos ser ou ter sofrido violência. Também pode haver pessoas que testemunharam violências ou sabem que isso aconteceu com alguém próximo. Este é um lembrete para todos nós, para sermos sensíveis a essas experiências durante nosso tempo juntos.”

Explique que parte do material apresentado pode desencadear gatilhos em participantes que já sofreram violência. Informe aos participantes que podem sair da sala, caso se sintam desconfortáveis. Incentive o autocuidado, conforme necessário.

Escreva em um quadro ou flip chart pelo menos um recurso para mulheres em situação de violência que esteja disponível durante o treinamento e incentive as pessoas a usá-lo, caso sintam necessidade.

Regras básicas: Explique que é importante estabelecer um conjunto de regras básicas para o treinamento.

Peça para as pessoas sugerirem regras básicas para o treinamento. Escreva-as em um flip chart.

Pergunte e adicione o que estiver faltando à lista (Slide 4):

� Pontualidade - tanto no comparecimento quanto na hora de expressar seu ponto de vista

� Aprender e trabalhar juntos

16Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde.

� Contribuir para atingir os objetivos – participar ativamente, registrar os resultados do curso, voluntariar-se para liderar/mediar exercícios

� Respeitar uns aos outros

� Ouvir com uma mente aberta

� Permitir que todos participem

� Expressar discordâncias de forma respeitosa

� Dar feedback de maneira construtiva (começando com o positivo)

� Não interromper enquanto as pessoas estão falando

� Ajudar a criar um espaço seguro

� Respeitar a confidencialidade. Qualquer informação pessoal compartilhada fica na sala

� Estar presente

� Usar dispositivos eletrônicos como celulares ou laptops apenas para emergências

Explique que essas regras básicas são bem-vindas ao treinamento e que mais sugestões podem ser feitas à medida que o treinamento avança.

Exercício: Medo e motivações em um chapéu (30 minutos)

Objetivos de aprendizagem do exercício (slide 5)

� Reconhecer e entender as preocupações dos profissionais de saúde sobre o cuidado de pessoas que sofreram violência sexual e por parceiro íntimo

� Complementar as motivações e os pontos fortes dos profissionais para lidar com a violência sexual e por parceiro íntimo.

Instruções para facilitadores (slide 6)

� Dê dois pedaços de papel para cada participante.

� Coloque dois chapéus ou caixas para os participantes colocarem seus papéis dentro.

� Peça para os participantes escreverem:

� em um pedaço de papel, algo que os incentiva a enfrentar a violência sexual e por parceiro íntimo

� em um segundo pedaço de papel, um medo que eles têm ao enfrentar a violência sexual e por parceiro íntimo.

� Peça para os participantes dobrarem os pedaços de papel e colocá-los nos chapéus – os medos em um e as motivações em outro.

� Pegue aleatoriamente uma resposta do chapéu dos “medos” e leia para o grupo. Discuta com os participantes e pergunte como esse medo pode ser superado.

� Faça isso duas ou mais vezes, dependendo do tempo.

� Em seguida, pegue uma resposta do chapéu de “motivações” e leia para o grupo. Discuta a motivação com os participantes e peça sugestões sobre como o treinamento pode potencializar isso.

� Faça isso duas ou mais vezes, dependendo do tempo.

Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde. 17

� Durante um intervalo, fixe todas as respostas em dois flip charts separados (barreiras/medos em um e motivações no outro), organizados por temas/áreas gerais, para se referir a eles durante o treinamento.

(Se o tempo permitir, vale a pena incluir uma sessão curta mais ao final do treinamento para revisitar essas respostas e ver quantos medos foram abordados durante o treinamento e discutir os demais.)

Lições importantes (slide 7)

� Muitos profissionais podem ter preocupações sobre trazer à tona o tópico da violência com seus pacientes. É comum temer que isso possa desencadear suas próprias memórias relacionadas a experiências ou testemunhos de abuso, ou podem se sentir despreparados para lidar com a violência.

� No entanto, dados sugerem que, se os profissionais mencionarem o tema da violência e responderem com empatia, isso pode fortalecer a mulher em situação de violência.

� Muitos de nós somos apaixonados por prover cuidado e garantir saúde e justiça para nossas pacientes. Essa energia positiva pode guiar nossa forma de colocar em prática este treinamento.

18Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde.

Sessão 1. A violência contra mulheres como um problema de saúde pública

Preparação e informações gerais

Objetivos de aprendizagem e competências

Objetivo 1: Demonstrar conhecimento geral sobre a violência contra mulheres como um problema de saúde pública.

Competências

� Conhecer a epidemiologia das diferentes formas de violência contra mulheres em níveis global e local.

� Conhecer as consequências da violência contra mulheres sobre a saúde.

� Entender o papel e as limitações de profissional de saúde no manejo da violência contra mulheres.

� Saber sobre as diretrizes clínicas e de políticas públicas e o Manual Clínico da OMS sobre respostas à violência por parceiro íntimo e à violência sexual contra as mulheres.

Duração da sessão 40 minutos

(Pode ser necessário tempo extra para apresentações referentes ao país.)

Técnicas de treinamento

� Vídeo (5 minutos)

� Apresentação com slides e discussão (35 minutos)

Materiais de apoio Violência contra mulheres: panorama global/resposta da saúde

� Abordando barreiras dos profissionais de saúde no manejo da violência contra mulheres

� Por que a resposta do(a) profissional de saúde importa?

Conteúdo da sessão

Contexto � A violência contra mulheres é um grande problema de saúde pública e de saúde das mulheres. Ela está enraizada na desigualdades de gênero. Ela é uma violação dos direitos humanos.

� Mulheres em situação de violência têm direito ao mais alto padrão possível de assistência em saúde. Os profissionais de saúde têm a obrigação de cumprir este direito, e estão em uma posição única para apoiar mulheres que sofrem violência. Esses profissionais podem criar um ambiente seguro e confidencial apropriado para facilitar o relato da violência e oferecer uma resposta empática, fornecendo tratamento adequado e encaminhamento a outros recursos e serviços.

� Vamos começar assistindo a um vídeo curto sobre o fortalecimento do sistema de saúde para enfrentar a violência.

Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde. 19

Vídeo (5 minutos) Explique que agora será apresentado um breve vídeo de 3 minutos.

Apresente o vídeo deste link (slide 3):

https://www.youtube.com/watch?v=Qc_GHITvTmI

Apresentação de slides e discussão (35 minutos)

Os slides da Sessão 1 cobrem o seguinte conteúdo (para detalhes, veja as notas no arquivo PowerPoint):

Definições e formas de VCM (violência contra mulheres) (slides 4 a 6)

� Leia sobre a definição global (slide 5).

� A violência contra mulheres tem muitas formas. Violência por parceiro íntimo (um tipo de violência doméstica) é a forma mais comum de violência contra mulheres no mundo (slide 6).

� Peça aos participantes para refletirem e discutirem outros exemplos de violência não listados, e quais formas de abuso são mais comuns em seus ambientes e reconhecidos pela legislação.

Prevalência da VCM (slides 7 a 12)

� Distribua o material de apoio “Violência contra mulheres: panorama global/resposta da saúde”.

� Destaque as estimativas global e regional de violência por parceiro íntimo e violência sexual (slides 8 a 9 e material de apoio). (Adicione dados de prevalência local, slide 10.)

� Destaque grupos que podem estar em maior risco ou que são particularmente relevantes para profissionais de saúde (como grávidas, mulheres vivendo com HIV, mulheres com deficiências, mulheres indígenas e mulheres que trabalham com sexo) (slide 12).

Consequências socioeconômicas da VCM (slides 13 a 15)

� Destaque as diversas consequências físicas e mentais de curto e longo prazo (slide 14) para a saúde das mulheres e seus filhos(as) (slide 15).

� Descreva as consequências sociais e econômicas (slide 15).

Papel dos profissionais de saúde (slides 16 a 21)

� As mulheres costumam ver os profissionais como modelos da comunidade e dignos de confiança (slide 17).

� Mulheres em situação de violência podem ter necessidades emocionais, necessidade de reafirmação e preocupações contínuas com a segurança, além de necessidades de saúde física (slide 18).

� O papel dos profissionais é apoiar e oferecer cuidado com empatia, além de encaminhar para outros serviços, quando disponíveis (slide 19). Os profissionais não são responsáveis por resolver a violência ou questões relacionadas, nem tomar decisões pela mulher (slide 20).

� Ignorar a violência pode causar danos. Por isso, é importante analisar as possíveis consequências dos comportamentos dos profissionais (slide 21)

Ferramentas e diretrizes da OMS para profissional de saúde (slides 22 a 25)

� Observe as diretrizes clínicas da OMS e as diretrizes de políticas públicas para lidar com a violência sexual voltada a crianças e adolescentes (slide 23).

20Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde.

� E duas ferramentas de implementação – o Manual Clínico para profissionais de saúde (slide 24) e o manual para gestores de saúde (slide 25).

Os slides 24 e 25 sobre ferramentas de implementação podem ser deixados de fora se o tempo for curto, porque esse conteúdo será abordado mais tarde.

Lições importantes (slide 26 e 27)

Observe que os tópicos desta sessão serão explorados a fundo mais tarde.

Pergunte se há pontos que precisam ser esclarecidos agora (10 minutos).

Distribua o material de apoio para ler após a aula: “Abordando as barreiras dos profissionais de saúde no manejo da violência contra mulheres” e “Por que a resposta dos profissionais de saúde importa?”.

Fechamento Pergunte se há dúvidas ou questões.

Reforce as mensagens principais:

� A violência afeta a saúde física e mental das mulheres.

� Os profissionais de saúde têm um papel importante a desempenhar no apoio e cuidado das mulheres em situação de violência.

� Como profissionais de saúde, podemos ter receios sobre abordar a violência vivenciada por mulheres que buscam serviços de saúde, mas muitos de nós somos profundamente comprometidos em melhorar a saúde e o bem-estar dessas mulheres que procuram cuidados.

� Este treinamento foi feito para construir conhecimento, habilidades e confiança para responder efetivamente a pessoas que sofreram violência.

Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde. 21

Sessão 2. A experiência da mulher em situação de violência e como os valores e crenças dos profissionais de saúde afetam o cuidado prestado

Preparação e informações gerais

Objetivos de aprendizagem e competências

Objetivo 2: Demonstrar comportamentos e compreender valores que contribuam para uma cultura segura e de apoio.

Competências

� Demonstrar autoconsciência sobre suas crenças, suposições, possíveis preconceitos e respostas emocionais que podem afetar as interações com mulheres em situação de violência.

� Entender as circunstâncias e as barreiras que as mulheres que sofrem violência encontram ao buscar apoio.

� Reconhecer a importância de ter empatia com as mulheres em situação de violência

Duração da sessão 80–140 minutos

Técnicas de treinamento

Exercício 2.1: para explorar valores e crenças de profissionais de saúde

� Opção A: Mito ou fato? (15 minutos)

� Opção B: Votando com os pés (30 minutos)

Exercício 2.2: para entender a experiência das mulheres em situação de violência

� Opção A: Coberta pela culpa (45 minutos)

� Opção B: No lugar dela (75 minutos)

Se houver 60 minutos disponíveis para os exercícios, você pode conduzir o Exercício 2.1 Opção A + Exercício 2.2 Opção A

Se houver 90 minutos disponíveis para os exercícios, você pode conduzir o Exercício 2.1 Opção A + Exercício 2.1 Opção B + Exercício 2.2 Opção A ou Exercício 2.1 Opção A + Exercício 2.2 Opção B

Se houver 120 minutos disponíveis para os exercícios, você pode conduzir o Exercício 2.1 Opção A + Exercício 2.1 Opção B + Exercício 2.2 Opção B

Discussão guiada (20 minutos)

� Por que as mulheres não terminam o relacionamento (10 minutos)

� Barriers to care-seeking (10 minutos)

22Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde.

Materiais para facilitadores

Exercício 2.1, Opção A – Mito ou fato?

� Recurso para facilitadores

Exercício 2.1, Opção B – Votando com os pés

� Recurso para facilitadores

� Duas plaquinhas – uma que diz “concordo” e outra que diz “discordo”

Exercício 2.2, Opção A – Coberta pela culpa

� 11 lenços ou folhas de jornal

� 12 fichas de personagens

Exercício 2.2, Opção B – No lugar dela (requer preparação prévia)

� Instruções para facilitadores – veja também o material em: http://raisingvoices.org/innovation/ creating-methodologies/in-her-shoes/

� 15 estações (papel A3 ou A4 ou fichas coloridas com um destino ou personagem escrito em cada um)

� Material de apoio do participante – fichas de histórias para cada grupo

Materiais de apoio � Why don’t women leave?

� Barreiras na busca pelo cuidado

Conteúdo da sessão

Contexto Apresente a sessão explicando que, para lidar com a violência contra mulheres, é necessário entender como, enquanto profissionais de saúde, nossos valores, crenças e atitudes podem afetar como prestamos cuidados e como nos identificamos com as experiências das mulheres que sofrem violência e buscam ajuda. Essas crenças e valores são frequentemente moldados pelas mesmas normas sociais que reforçam a estigmatização de mulheres que sofrem violência. As atividades desta sessão ajudam os participantes a refletir criticamente sobre essas crenças e valores, além das normas subjacentes em que eles são baseados, reconhecendo mitos comuns e crenças sobre violência contra mulheres, compreendendo a experiência das que buscam ajuda, e esclarecendo como nossas crenças/ valores podem afetar o cuidado que prestamos.

Exercício 2.1, Opção A: Mito ou fato? (15 minutos)

Objetivo de aprendizagem do exercício

� Refletir criticamente sobre nossas percepções e crenças que afetam o cuidado que prestamos às mulheres em situação de violência.

Instruções para facilitadores (slide 3)

� Explique que você gostaria de gastar algum tempo explorando alguns mitos comuns sobre violência.

� Peça para os participantes compartilharem crenças locais que tenham ouvido relacionadas à violência contra mulheres.

� Leia a primeira afirmação do recurso para facilitadores “Mito ou fato?” para o grupo.

Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde. 23

� Pergunte ao grupo se eles acham que isso é um fato ou um mito. Veja se há consenso dentro do grupo ou não.

� Peça a uma pessoa que acredita ser um fato e a outra que acredita ser um mito para explicar seus pontos de vista.

� Dê a resposta. Diga se a afirmação é um mito ou um fato e mostre o porquê.

� Repita isso para outras três afirmações. (Selecione afirmações que pareçam mais relevantes para o grupo.) Não gaste mais de 3 minutos em cada afirmação.

Para ver as perguntas para discussão e as lições importantes, veja as seções abaixo do Exercício 2.1, Opção B: Votando com os pés.

Exercício 2.1, Opção B: Votando com os pés (30 minutos)

Objetivo de aprendizagem do exercício

� Refletir criticamente sobre nossas percepções e crenças que afetam o cuidado que prestamos às mulheres em situação de violência.

Instruções para facilitadores (slide 4)

� Encontre um espaço onde os participantes possam se mover facilmente.

� Se o grupo for muito grande, divida em dois ou três grupos e conduza o exercício em 2 ou 3 espaços diferentes (por exemplo, uma sala de descanso ou diferentes extremidades da sala).

� Peça aos participantes em cada grupo para ficar no meio da sala em uma linha reta.

� Coloque uma plaquinha (usando flip charts ou pedaços de papel grandes) com as palavras “Concordo” em um lado da sala e “Discordo” no lado oposto.

� Leia em voz alta uma das afirmações listadas no recurso para facilitadores.

� Peça para os participantes responderem movendo-se em direção a uma das plaquinhas – Concordo ou Discordo – dependendo se concordam ou discordam da afirmação.

� Peça para os participantes escolherem quão perto da plaquinha eles estão com base em quanto concordam ou discordam da afirmação.

� Após cada afirmação, conduza uma discussão sobre por que as pessoas escolheram cada lado. Isso ajudará a entender melhor suas crenças subjacentes.

� Peça para cada lado explicar seu ponto de vista para o outro. Reserve um tempo para debater.

� Após um curto debate, pergunte se alguém gostaria de mudar de posição.

� Repita isso lendo mais 4 a 5 afirmações, dependendo de quanto tempo houver disponível.

Perguntas para discussão do Exercício 2.1, Opção A ou B

Perguntas para discussão do Exercício 2.1 (Opção A ou B)

� Após terminar o exercício, conduza uma discussão em grupo usando as seguintes perguntas como ponto de partida:

� Como você se sentiu confrontando valores diferentes dos seus?

� O que você aprendeu com essa experiência?

� Isso mudou sua opinião sobre algum dos assuntos?

� Estimule o debate dentro do grupo e se prepare para passar um tempo discutindo essas questões.

24Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde.

Lições importantes do Exercício 2.1, Opção A ou B

Lições importantes (slide 5)

� O propósito deste exercício é refletir sobre como nossos valores e crenças pessoais sobre violência contra mulheres podem afetar o cuidado que prestamos como profissionais de saúde.

� Muitas vezes, nossas crenças e atitudes refletem as normas e valores da sociedade em que vivemos. É importante refletir sobre essas normas e se elas podem ser prejudiciais para as mulheres em situação de violência. Precisamos questionar essas normas e introduzir modelos saudáveis para pacientes e comunidades.

� Mulheres em situação de violência muitas vezes estão cientes e conseguem perceber quando as pessoas têm crenças negativas e opiniões sobre elas. Estamos cientes de nossas crenças negativas, então é melhor evitar comunicá-las para não causar mais sofrimento.

� Mudar mentalidades exige tempo. No entanto, é possível mudar nossas crenças, e é saudável adaptá-las se necessário.

Exercício 2.2, Opção A: Coberta pela culpa (45 minutos)

Objetivos de aprendizagem do exercício (slide 6)

� Aumentar a conscientização e empatia pelas dificuldades que mulheres que sofrem violência enfrentam ao buscar apoio.

� Destacar como as normas e comportamentos sociais desiguais podem afetar a capacidade das mulheres de buscar ajuda jurídica e geral.

� Incentivar participantes a pensar sobre o que podem fazer como profissionais para oferecer uma resposta empática a mulheres em situação de violência.

Instruções para facilitadores (slide 7)

� Prepare 11 lenços ou folhas de jornal.

� Peça para 12 pessoais participarem da atividade. Convide os outros para assistir.

� Peça para uma pessoa assumir o papel de Maria (mude o nome de acordo com o país), uma mulher que sofreu violência. Peça para as outras 11 assumirem outros papéis, escritos nos fichas de personagens.

� Forneça a cada um dos 12 participantes uma ficha de personagem. (Material de apoio: Coberta pela culpa).

� Peça para Maria se sentar no meio. Ela se senta em uma cadeira de frente para os outros participantes.

� Instrua os outros participantes a ficarem em volta da Maria em um círculo, virados para fora (de costas para a Maria). Cada um segura um lenço ou folha de jornal.

� Como facilitador(a), fique fora do círculo e leia a história da Maria (Material de apoio: Coberta pela culpa). Depois, na ordem dos personagens listados abaixo, explique para quem Maria pede ajuda.

� Peça para cada personagem ler a afirmação na ficha de personagem e depois dar um passo para frente e colocar um lenço/jornal na Maria.

� Ordem para cobrir Maria com um lenço/jornal: amigo(a), mãe DELA, vizinho(a), mãe DELE, agente comunitário de saúde [do sexo feminino], líder religioso, filha, policial, assistente social, advogado(a), médico(a)

Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde. 25

� Depois de todos os 11 personagens terem colocado um lenço/jornal na Maria, pergunte à Maria por que ela não deixou o parceiro. Espere pela resposta dela.

� Depois, peça para cada personagem reverter o processo lendo a declaração na ficha de personagem e remover um lenço/jornal da Maria. Desta vez, os personagens devem se mover em direção à Maria.

� Ordem para remover o lenço/jornal da Maria: médico(a), advogado(a), assistente social, policial, filha, líder religioso, advogado, policial, trabalhador da comunidade, pastor, profissional de saúde comunitária, mãe DELE, vizinho, mãe DELA, amigo(a).

� Os participantes têm 30 minutos para este exercício. Depois disso, a pessoa que estiver facilitando deve mediar uma discussão em grupo de 15 minutos.

Perguntas para discussão (registre as respostas em um flip chart e volte a elas mais tarde no treinamento)

Pergunte:

� Como a Maria se sentiu?

� Como cada um dos outros personagens se sentiu? (Peça voluntários para responder.)

� Como os observadores se sentiram? (Peça voluntários para responder.)

Discuta:

� Como você se sentiu sobre o pedido de ajuda da mulher e sobre as escolhas que ela teve que fazer?

� Pergunte: Ela sempre foi livre ou ela tinha o poder de tomar a decisão e procurar ajuda?

� Como as pessoas que a Maria procurou reagiram a ela?

� Pergunte: Como elas poderiam ter feito isso de uma maneira melhor?

Lições importantes: Veja as mensagens principais após as instruções de “No lugar dela”, abaixo.

Exercício 2.2, Opção B: No lugar dela (75 minutos)

Objetivos de aprendizagem do exercício (slide 8)

� Aumentar a conscientização e empatia pelas dificuldades que mulheres que sofrem violência enfrentam ao buscar apoio.

� Destacar como normas de gênero desiguais e comportamentos podem afetar a habilidade das mulheres de buscar ajuda jurídica e geral.

� Incentivar participantes a pensar sobre o que podem fazer como profissionais para oferecer uma resposta empática a mulheres em situação de violência.

Instruções para facilitadores (slide 9)

� Prepare as “15 estações”:

Escreva as seguintes palavras, uma em cada pedaço de papel: Religião; Amigos e vizinhos; A violência ocorre; Polícia; Unidade de saúde; ONG; Trabalho; Surpresa; Líder local; Líder religioso; Continuar; Educação; e Abrigo. (Você pode adicionar outros personagens relevantes para o seu contexto, caso haja.)

Espalhe esses papéis pelo ambiente. Coloque-os em posições que facilitem o movimento dos participantes. Se possível, adicione itens temáticos para facilitar a narrativa – por exemplo, lápis e bloco de notas em “Educação”.

26Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde.

Disponha cada ficha de história das diferentes estações na estação correspondente, garantindo que as diferentes histórias estejam próximas umas da outras e que as fichas correspondentes à mesma história estejam empilhados, com o número mais baixo no topo. (Por exemplo, uma pilha na estação “A violência ocorre” com: Ana A violência ocorre 1 e, abaixo desse, Ana A violência ocorre 2, etc. Próximo a isso: Beth A violência ocorre 1 e, abaixo desse, Beth A violência ocorre 2, etc.

� Explique: Este exercício nos dará a chance de nos colocar no lugar de uma mulher que sofreu violência. Vamos fazer as decisões que ela enfrenta e discutir essas decisões.

Divida o grupo em grupos menores de 3 a 5 participantes cada.

� Explique que esta é uma experiência guiada e cada grupo tomará decisões discutindo e chegando a um consenso.

� Dê a cada grupo a identidade de uma personagem diferente. Se houver mais grupos do que personagens, crie mais fichas de personagens. Faça os grupos com a mesma identidade começarem com 5 minutos de intervalo para evitar que se aglomerem nos mesmos locais ao mesmo tempo. (Veja as fichas de personagens e de situação para “No lugar dela”.)

� Peça para os participantes seguirem as instruções na parte de baixo das fichas. Em cada estação, os participantes vão encontrar uma ficha que corresponde ao personagem. Peça para os participantes do grupo lerem e discutir as decisões com base no personagem da ficha.

� Os participantes têm 45 minutos para o exercício. Depois disso, a pessoa que estiver facilitando deve mediar uma discussão de 30 minutos em grupo.

Perguntas para discussão (registre as respostas em um flip chart e volte a elas conforme necessário)

Pergunte:

� Como se sentiu ao caminhar pela história da mulher? Conseguiram se colocar no lugar dela?

� Como você se sente sobre as opções dela para ajuda e as escolhas que ela teve que fazer?

� Pergunte: Ela sempre foi livre ou ela tinha o poder de tomar a decisão e procurar ajuda?

� Como as pessoas que ela abordou responderam à mulher em situação de violência?

� Pergunte: Como elas poderiam ter feito isso de uma maneira melhor?

Lições importantes do Exercício 2.2, Opção A ou B

Lições importantes do exercício (slides 10 e 11)

� Este exercício ilustra as decisões desafiadoras que as mulheres enfrentam ao lidar com a violência e como as pessoas respondem a elas.

� Mulheres tomam decisões importantes de segurança o tempo todo e elas são as especialistas em suas próprias situações. Porém, muitas vezes, elas têm poucas opções para buscar ajuda e apoio, se tanto. Muitos fatores podem impedir uma mulher de encontrar ajuda, incluindo barreiras econômicas, estigma social, obstáculos jurídicos e ameaças de violência física.

� Quando a violência contra mulheres é normalizada, elas muitas vezes sentem que devem simplesmente aceitá-la. Muitas mulheres em situação de violência são questionadas ou ignoradas. Por isso, elas sentem que precisam permanecer nas situações de violência. Essas situações são resultado das normas de gênero desiguais das nossas comunidades.

� A violência contra mulheres nunca pode ser justificada. Não importa se ela é casada ou não, o que veste, como age, qual sua religião ou qualquer outro fator. É importante NUNCA colocar qualquer tipo de culpa na mulher.

Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde. 27

� Profissionais de saúde podem ajudar mulheres em situação de violência de várias maneiras, como:

� entrar em contato com mulheres suspeitas de estar em situação de violência e perguntar sobre isso

� ouvir as histórias das mulheres em situação de violência

� demonstrar empatia, que pode fazer uma enorme diferença para a mulher

� acreditar nas experiências da mulher e não a culpar pela violência

� perguntar sobre suas necessidades e preocupações, além de incentivá-las a buscar alternativas

� apoiar mulheres a tomar as decisões que elas consideram certas e respeitar a vontade e as escolhas delas.

Vamos voltar a esses temas durante o treinamento.

Encerre o exercício com uma reflexão sobre o que sentiram: Peça aos participantes para escreverem em seus cadernos sobre a experiência que tiveram durante esta atividade.

Discussão guiada (20 minutos)

Passe para uma discussão guiada sobre a nível de preparo das mulheres para mudar e as barreiras que elas podem enfrentar ao buscar cuidados.

Explique que a intenção é complementar o exercício e entender as situações das mulheres pensando em duas perguntas:

Pergunta 1: Quando ouvimos sobre a experiência de violência das mulheres, podemos nos perguntar, “Por que ela não simplesmente termina o relacionamento?”

Faça a mediação do debate.

� Abra a discussão perguntando por que alguém poderia não deixar um emprego que ela tinha há muito tempo e onde recebia um bom salário.

� Pergunte aos participantes se eles já imaginaram por que mulheres não saem de situações violentas. Se sim, por que eles acham que elas não saem do relacionamento? Baseie-se nos materiais de apoio Why don’t women leave?

� Pergunte sobre barreiras individuais, sociais, culturais, econômicas e institucionais.

� Existem outras razões que não foram mencionadas aqui?

� Há algum outro motivo pelo qual mulheres em nosso contexto específico podem não buscar ajuda?

Pontos principais para discussão:

� A mudança é um processo. As mulheres nem sempre estão prontas para agir por várias razões, e elas podem nunca estar prontas. No entanto, os profissionais sempre devem estar prontos para agir, então, quando ela estiver pronta, ela receba o apoio necessário. Até mesmo ajudar uma mulher para que busque cuidado ou adote medidas de segurança já é uma contribuição valiosa.

� Profissionais de saúde podem ser úteis para ajudar as mulheres a enfrentar o medo e estabelecer normas que deixem claro que o abuso não faz parte de relacionamentos saudáveis.

Pergunta 2: Também podemos perguntar: “Por que mulheres que sofrem violência adiam a busca por ajuda?”

28Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde.

Conduza uma discussão sobre quais barreiras impedem ou fazem as mulheres adiar a busca por cuidados relacionados à violência. Baseie-se no material de apoio “Barreiras na busca pelo cuidado”.

� Pergunte quais podem ser as barreiras individuais, sociais, culturais, econômicas e institucionais.

� Existem outras razões que não foram mencionadas aqui?

� Há algum outro motivo pelo qual mulheres em nosso contexto específico podem não buscar ajuda?

� Existem outras razões pelas quais mulheres podem não buscar ajuda?

� Como podemos ajudar as mulheres a receber a ajuda que precisam?

Pontos principais para discussão:

� As razões que fazem as mulheres não saírem de relacionamentos abusivos também fazem com que elas não busquem ajuda.

� O estudo multipaíses da OMS descobriu que a maioria das mulheres que havia sofrido violência por um parceiro íntimo não tinha contado a ninguém sobre a violência (quando o fizeram, foi mais frequentemente a amigos e família). Elas também não buscaram ajuda de um profissional ou agência; quando o faziam, era principalmente em serviços de saúde.

� Alguns dos motivos mais comuns para procurar ajuda (assistência social) refletem “pontos de virada”, como os seguintes:

� Ela não aguentou mais.

� Ela foi gravemente ferida ou temia por sua vida (ou pela vida de seus filhos).

� Seu parceiro havia ameaçado bater nos filhos.

� Ela foi incentivada por amigos ou família.

� Queremos prevenir mais abuso, mas é essencial que as mulheres estejam no controle do processo para determinar quando e como querem mudar. Estar ciente das barreiras ajuda os profissionais de saúde a apoiá-la, por exemplo, assegurando que a mulher não é a culpada e ajudando ela a entender como a violência pode se agravar e como isso afeta a saúde dela.

� Reconheça que alcançar a segurança é um processo de longo prazo para mulheres em situação de violência e que o conceito de segurança difere para cada pessoa.

Distribua os materiais de apoio Why don’t women leave? e Barriers to seeking care.

Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde. 29

Fechamento Pergunte se há dúvidas ou questões.

Fale as mensagens principais (slide 12):

� Os exercícios desta sessão ilustram as situações, decisões e respostas desafiadoras que mulheres em situação de violência enfrentam. Ao nos colocarmos no lugar da mulher em situação de violência, podemos criar empatia e entendê-la melhor.

� Como profissionais de saúde, é importante refletir sobre nossos valores e crenças, como eles moldam a sociedade e como transmitimos isso a pacientes, estigmatizando a mulher e causando mais trauma. É importante NUNCA culpar a mulher de forma alguma. Também podemos lembrar aos outros para não culparem as mulheres pela violência que sofreram.

� Dadas a barreiras para terminar relacionamentos ou até compartilhar experiências de abuso, é importante lembrar que a segurança é um objetivo a longo prazo.

� Como profissionais, sempre encorajamos as mulheres a procurar opções em suas vidas e as apoiamos naquilo que elas acreditam ser o melhor para elas.

30Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde.

Sessão 3. Princípios orientadores e visão geral da resposta de saúde à violência contra mulheres

Preparação e informações gerais

Objetivos de aprendizagem e competências

Objetivo 2: Demonstrar comportamentos e compreender valores que contribuam para uma cultura segura e de apoio.

Competências

� Conhecer os princípios orientadores para fornecer cuidado centrado na mulher de uma forma culturalmente apropriada.

� Entender como colocar em prática os princípios orientadores do cuidado centrado na mulher.

Duração da sessão 30 minutos

Técnicas de treinamento

Apresentação com slides (30 minutos)

Materiais de apoio Pôster ou ficha pequena resumindo a abordagem ANIMA (acolhimento inicial)

Leitura de apoio Manual Clínico, páginas 3 a 5

Conteúdo da sessão

Contexto Apresente a sessão explicando que o Manual Clínico da OMS, que é a principal referência para este treinamento, foi desenvolvido usando o cuidado centrado na mulher como base para uma resposta apropriada e de apoio à violência contra mulheres.

Neste treinamento, vamos entender e aprender como aplicar esses princípios na prática clínica. Também vamos começar a nos familiarizar com a estrutura geral e o conteúdo do Manual Clínico.

Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde. 31

Apresentação com slides e discussão guiada (30 minutos)

Os slides da Sessão 3 cobrem o seguinte conteúdo (para detalhes, veja as notas no arquivo PowerPoint):

Princípios orientadores (slides 3 a 8)

� Os dois princípios fundamentais para o cuidado centrado na mulher são o respeito pelos direitos humanos e a promoção da igualdade de gênero (slides 4 a 6).

� Privacidade, segurança e confidencialidade são essenciais para fornecer cuidados a mulheres em situação de violência (slide 7).

� Existem outras considerações adicionais para crianças e adolescentes que sofreram abuso sexual (slide 8). Elas são baseadas nos princípios do que é melhor para a criança e no desenvolvimento de capacidades.

Conteúdos do Manual Clínico (slides 9 e 10)

� O restante desta sessão apresenta uma visão geral do Manual Clínico.

Manual Clínico parte 1: Identificando mulheres que sofrem violência (slides 11 a 13)

� Discutir pontos de entrada para atenção à saúde de mulheres em situação de violência em seus contextos (slide 12).

� Diferença entre triagem universal e investigação clínica. A OMS não recomenda a triagem universal para violência por parceiro íntimo, mas sim uma investigação clínica (slide 13).

Manual Clínico parte 2: Acolhimento inicial (slides 14 a 16)

Ferramenta de apoio ao trabalho: ANIMA

� A sigla “ANIMA” pode ajudar a lembrar os elementos do acolhimento inicial (slide 15). Este treinamento desenvolve as habilidades mencionadas na sigla “ANIMA”. (Esse conceito é adaptado dos primeiros socorros de apoio psicológico.)

� Se você tem apenas uma hora para treinar profissionais de saúde no acolhimento inicial, você deve ensinar a abordagem ANIMA. Indique a ferramenta ANIMA (na página 14 ou na ficha na última página do Manual Clínico, ou ainda no pôster ANIMA).

� Mostre o protocolo resumido de cuidados para mulheres em situação de violência por parceiro íntimo (slide 16).

Manual Clínico parte 3: Cuidado clínico para agressão/abuso sexual (slides 17 e 18)

� Mostrar o protocolo resumido de como cuidar de mulheres que sofreram agressão/abuso sexual (slide 18).

� O treinamento segue as etapas definidas nos protocolos resumidos.

Manual Clínico parte 4: Cuidado da saúde mental (slides 19 e 20)

� Mesmo sem formação como um especialista em saúde mental, você pode oferecer apoio psicossocial breve, avaliar a condição da saúde mental para identificar indícios de depressão, ideação suicida ou estresse pós-traumático e encaminhar a um especialista se necessário. O treinamento vai abordar essas etapas básicas (slide 20).

Adendos do Manual Clínico: Considerações sobre planejamento reprodutivo e HIV (slides 21–22)

� Mulheres que buscam serviços de planejamento reprodutivo ou testagem de HIV podem sofrer violência e enfrentar desafios específicos relacionados ao uso de contraceptivos ou a comunicação do diagnóstico de HIV.

32Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde.

� Nesses contextos, profissionais de saúde não precisam só de treinamento para identificar a violência e oferecer acolhimento inicial; eles também precisam saber como oferecer aconselhamento sobre planejamento reprodutivo e comunicar o diagnóstico de HIV tendo em mente a necessidade de segurança das mulheres.

As duas responsabilidades dos gestores: não denunciar a violência para as autoridades policiais e fortalecer os sistemas de saúde (slides 23 a 25)

� Considerações sobre notificação (slide 24): A OMS não recomenda notificar autoridades policiais sobre mulheres em situação de violência.

� Fortalecimento dos sistemas de saúde (slide 25): Este treinamento não entra em detalhes sobre aspectos de gestão, mas participantes com responsabilidades administrativas podem consultar o manual para gestores de saúde para saber como fortalecer sistemas.

Fechamento Pergunte se há dúvidas ou questões.

Fale as mensagens principais (slide 26):

� A resposta do sistema de saúde deve ser baseada no respeito pelos direitos humanos e na promoção da igualdade de gênero.

� Este treinamento cobrirá e buscará desenvolver habilidades relacionadas às cinco partes do Manual Clínico da OMS.

� O sistema de saúde precisa ajudar os profissionais de saúde a colocar o treinamento em prática.

Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde. 33

Sessão 4. Habilidades de comunicação entre profissionais de saúde e a mulher em situação de violência

Preparação e informações gerais

Objetivos de aprendizagem e competências

Objetivo 2: Demonstrar comportamentos e compreender valores que contribuem para serviços seguros e acolhedores.

Competência

� Estabelecer uma comunicação empática e eficaz com pacientes/mulheres em situação de violência.

Duração da sessão 45 minutos

Técnicas de treinamento

Discussão e apresentação (15 minutos)

� Exercício 4.1: Escuta ativa (30 minutos)

Materiais de apoio � Active listening principles

Leitura de apoio Manual Clínico, páginas 42 a 45, seção “Comunicar”, página 89, “Dicas para conversar com pacientes”

Conteúdo da sessão

Contexto Apresente a sessão mencionando que a escuta é o primeiro elemento da abordagem ANIMA. Escutar é algo que fazemos o tempo todo, mas nem sempre escutamos de maneira consciente ou atenta. Uma boa capacidade de ouvir exige prática. Ela pode ser um grande diferencial na hora de deixar as mulheres em situação de violência à vontade para contar suas experiências, além de fazê-las se sentir apoiadas para que comecem a lidar com a violência mais rapidamente.

Vamos usar esta sessão para refletir e praticar essa arte e saber o que define uma boa habilidade de escuta.

34Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde.

Discussão e apresentação (15 minutos)

Discussão: Como sabemos se alguém está nos ouvindo?

Os slides da Sessão 4 cobrem o seguinte conteúdo (para detalhes, veja as notas no arquivo PowerPoint):

Revisão dos princípios de escuta ativa

� Distribua o material de apoio Active listening principles e discuta práticas de escuta ativa (slide 3).

� Reveja e demonstre os princípios de uma boa postura de escuta (a sigla SOLER) (slide 4).

Exercício 4.1: Escuta ativa (30 minutos)

Objetivo de aprendizagem do exercício

� Valorizar e praticar a escuta ativa.

Instruções para facilitadores (slide 5)

� Peça para os participantes formarem duplas.

� Peça para os participantes contarem uma situação desafiadora em qualquer área da vida por cerca de 5 minutos. OBSERVAÇÃO: Não use um exemplo relacionado à violência, porque o tempo é muito curto para lidar com um caso desse tipo.

� Peça para a pessoa que está ouvindo praticar a escuta ativa, incluindo perguntas abertas, comunicação não verbal e respostas sem julgamento. Indique o material de apoio Active listening principles caso queiram relembrar as práticas de escuta ativa.

� Após 5 minutos, peça para os participantes trocarem de papéis, de modo que a pessoa que escutou primeiro agora conte sua história por cerca de 5 minutos e a outra escute de forma ativa.

Discussão guiada (slide 6)

Com o grupo todo, faça as seguintes perguntas aos participantes:

� O que sua dupla fez para mostrar que estava escutando atentamente?

� O que sua dupla disse que demonstrou a escuta ativa?

� O que sua dupla NÃO disse ou fez (coisas positivas e negativas)?

� Como você se sentiu depois?

Pergunte aos participantes quais habilidades de comunicação são mais úteis para o ambiente clínico e adequadas para o contexto deles.

Fechamento Pergunte se há dúvidas ou questões.

Fale as mensagens principais (slide 7):

� Mulheres em situação de violência muitas vezes são silenciadas por agressores, membros da família, outras pessoas na comunidade e até mesmo por profissionais de saúde. Por contraste, uma escuta ativa e acolhedora permite que as mulheres sejam ouvidas, um passo importante para remediar a situação e possibilitar a revelação da violência.

� É necessário que haja uma comunicação empática e efetiva ao longo de toda a interação.

� Use habilidades de comunicação verbal e não verbal.

� Comece fazendo perguntas abertas.

Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde. 35

Sessão 5. Quando e como identificar a violência por parceiro íntimo

Preparação e informações gerais

Objetivos de aprendizagem e competências

Objetivo 3: Demonstrar habilidades clínicas apropriadas à profissão e conhecimento especializado para responder à violência contra mulheres.

Competências

� Entender os critérios mínimos que precisam ser atendidos para perguntar e responder adequadamente à violência contra mulheres.

� Reconhecer os sinais e sintomas que sugerem violência por parceiro íntimo.

� Compreender quando e como perguntar sobre violência por parceiro íntimo.

� Demonstrar maneiras apropriadas de perguntar sobre violência por parceiro íntimo.

Duração da sessão 40 ou 70 minutos

Técnicas de treinamento

Apresentação com slides (10 minutos)

� Exercício 5.1, Opção A: Role sobre identificação de violência por parceiro íntimo (60 minutos) OU (dependendo do tempo disponível)

� Exercício 5.1, Opção B: Análises de caso sobre identificação de violência por parceiro íntimo (30 minutos)

Materiais de apoio � Asking about violence

Materiais para facilitadores

Role play sobre identificação de violência por parceiro íntimo (Exercício 5.1, Opção A)

� Análises de caso sobre identificação de violência por parceiro íntimo (Exercício 5.1, Opção B)

Leitura de apoio Manual Clínico, páginas 8 a 11

Conteúdo da sessão

Contexto Lembre aos participantes que os profissionais de saúde estão em uma posição única para ajudar mulheres em situação de violência por parceiro íntimo. Muitas vezes, as mulheres podem buscar ajuda sem a intenção específica de discutir a violência. Profissionais de saúde podem ser o primeiro ponto de contato para as mulheres em situação de violência.

36Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde.

Como profissional de saúde, você pode suspeitar e identificar mulheres em situação de violência (consulte a página 8 do Manual Clínico).

Apresentação com slides (10 minutos)

Os slides da Sessão 5 cobrem o seguinte conteúdo (para detalhes, veja as notas no arquivo PowerPoint):

� Antes de perguntar sobre a violência, é necessário estabelecer alguns critérios mínimos. Protocolos, treinamento, privacidade, confidencialidade e um sistema de encaminhamento (slide 4).

� Privacidade: Nunca discuta violência se outra pessoa (mesmo que seja um amigo) estiver presente ou consiga ouvir. Pode ser necessário pensar em uma estratégia para conseguir falar com a mulher sozinha, como pedir para a pessoa que está junto fazer um favor ou preencher um formulário.

� Lembrete: A OMS recomenda a investigação clínica. A triagem universal não é recomendada (slide 5). (Consulte a página 17 das diretrizes clínicas e de políticas da OMS para mais informações.)

� Muitas vezes, mulheres que sofrem violência por parceiro íntimo buscam serviços de saúde por causa de questões emocionais ou físicas. (Para saber quando suspeitar que uma mulher está sofrendo violência e questionar, consulte os slides 6 e 7 e a página 9 do Manual Clínico.)

� Quando perguntar sobre violência, primeiro mencione o tópico de forma indireta (slide 8), depois use uma abordagem mais direta se for apropriado (slide 9). Há exemplos de frases na ferramenta de apoio ao trabalho sobre violência doméstica na página 11 do Manual Clínico. É possível usar somente algumas dessas frases ou outras que forem consideradas adequadas.

� Frequentemente, as mulheres não vão falar sobre a violência (slide 10). Consulte também a página 12 do Manual Clínico.

Reforce o seguinte:

� Lembre-se dos princípios do cuidado centrado na mulher.

� Habilidades verbais e não verbais de comunicação são importantes para construir confiança quando e se a mulher estiver pronta para revelar o abuso e buscar ajuda.

� Ela pode não revelar violência na primeira vez que você perguntar (ou em momento algum) e você precisa respeitar essa decisão.

Conduza o exercício. Veja as instruções abaixo.

� Nas páginas 34 a 37 do manual e em um anexo online no site da OMS, você pode encontrar perguntas que os profissionais podem ter (slides 16 e 17), com respostas.

Exercício 5.1, Opção A: Role play sobre identificação de violência por parceiro íntimo (60 minutos).

Observação para facilitadores: Consulte as instruções para role plays no Anexo 5 para lembrar como dar feedback aos participantes.

Objetivos de aprendizagem do exercício (slide 11)

� Praticar formas adequadas de mencionar o tema da violência e perguntar sobre violência.

Cuidando de mulheres em situação de violência: Um currículo de treinamento da OMS para profissionais de saúde. 37

Observação: Escolha o Exercício 5.1, Opção A (60 minutos) ou 5.1, Opção B (30 minutos) dependendo do tempo disponível.

Instruções para facilitadores (slide 12)

Mostre um vídeo demonstrando profissionais de saúde perguntando sobre violência. Se não houver um vídeo disponível, uma dupla de facilitadores pode demonstrar o role play.

Para os role plays:

� Divida os participantes em trios.

� Peça para uma pessoa de cada grupo se voluntariar para o papel da paciente/mulher em situação de violência, outra para o papel de profissional de saúde e uma terceira para ser o(a) observador(a), que fornecerá feedback às outras duas.

� Distribua os cenários (Material de apoio para participantes – Identificação de violência por parceiro íntimo). Dê o cenário de paciente à mulher em situação de violência e ao(à) observador(a), mas não ao(à) profissional.

Explique o seguinte:

� As participantes leem o cenário. Elas desempenham o papel da mulher em situação de violência e descrevem seus sintomas ou condições para o(a) profissional de saúde. Elas não compartilham informações sobre a violência a menos que sejam questionados pelo(a) profissional de saúde.

� O trabalho do(a) profissional de saúde é fornecer cuidados e fazer perguntas relevantes. Se necessário, eles devem abordar o tópico de violência e/ou perguntar sobre violência.

� O papel do(a) observador(a) é ler o guia na página 11 do Manual Clínico e dar feedback ao(à) profissional sobre como a questão da violência for abordada. Sugestão para facilitadores: caminhe pela sala e peça para pelo menos uma paciente O(a) observador(a) também deve prestar atenção à comunicação não verbal, assim como à verbal.

Sugestão para facilitadores: caminhe pela sala e peça para pelo menos uma paciente NÃO revelar a violência diretamente. Isso permite que o(a) profissional de saúde pratique habilidades voltadas a dar apoio, mesmo que a violência não seja revelada.

Após 10 minutos de role play ou após a revelação de violência (caso ela ocorra mais cedo), o(a) observador(a) deve interromper o role play e discutir por 5 minutos:

� Como o(a) participante que está interpretando a mulher em situação de violência se sentiu falando com o(a) profissional?

� Peça para a pessoa que observou dar feedback sobre como o(a) profissional fez perguntas, como respondeu à mulher em situação de violência e como foi a comunicação não verbal.

� Peça para o(a) profissional de saúde refletir sobre quais outras ações poderiam ajudar a mulher.

Se houver tempo, peça para os participantes trocarem de papel e realizarem out