Gender-based violence: strengthening the role and scope of prehospital emergency care by promoting theory, policy and clinical praxis

Doctoral Thesis


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University of Cape Town

Gender-based Violence has a considerable prevalence globally, but it is South Africa that has recorded the highest femicide rate in the world. Prehospital Emergency Care providers appear to be well positioned (as first responders) to respond to abuse early. The aim was to understand and strengthen current/potential practice of domestic violence intervention by prehospital emergency medical systems in the context of global health-sector responses. The paradigm was critical theory and the methodology was exploratory sequential mixed methods. Interviews with managers/policy-makers, focus group discussions of clinician-educators and non-participant observation of simulated practice resulted in hypothesis generation. The quantitative phase involved a survey and cohort study with a screening intervention in a public emergency service. The qualitative phase found challenges and threats to responses require organisational/ideological change as paradoxical practice exists relative to the domestic violence behavioural pathology. Further, role-definition, identity and violence re-contextualisation is needed amidst ambivalent and contradictory positions. Emergent theoretical propositions include: typologies of victims, perpetrators and stakeholder responses; an eco-systemic relationship of state/societal expectations; and a 'conceptual compass' for preventing systemic research bias. The cohort study found bio-psycho-social responses and prehospital screening for domestic violence effective and that the evaluation of prehospital met/unmet need was prudent. The historical domestic violence detection rate was found to be 5,1/1000. A nine-fold increase in detection following the screening training and implementation translated to 47,9/1000 emergency care patients, with no adverse events. These rates are unprecedented for South African emergency care and support screening-policy implementation. The difference in domestic violence detection, quantifies the extent of the practice gap, with an alarming missed case detection of 42,8 per 1000 patients (females, 14 years plus). Conceptualisation of the emergency care burden of domestic violence and an awakening to the unacceptability of current practice is warranted. There is a risk of regulatory and organisational 'capture' mediated by masculine hegemony and resuscitation bias. Professionalization should enable a community of practice approach to violence prevention. Recommendations include the national implementation of screening policy; mitigation of regulatory capture risk and professionalising responses through curriculum-reform. The proposed Risk-Need-Responsivity practice-model promotes clinical coherence in Emergency Care. This elevation of the emergency care discourse is likely to benefit the victim and emergency medicine community. Research is warranted in the evolving epidemiology of domestic violence, the acute/clinical needs of victims/perpetrators and the role of emergency medical systems and surveillance, in promoting health and preventing the associated morbidity/mortality, both as a forensic emergency care burden and as a social determinant of health.