Overview of studies
Thirteen studies published from 2005–2022 were included in this systematic review. Nine of the studies were qualitative (33–41) and four were mixed methods (9, 42–45). Studies included 405 women experiencing family violence (95 pregnant & 79 postnatal) belonging to various countries. Table 2 summarizes the CASP checklist of studies, which demonstrates substantial strength in methodological approach.
Sample Recruitment And Demographics
All 13 studies used interviews or focus groups to collect data and applied a thematic analysis approach. Seven studies were from South Asian countries (Afghanistan, Bangladesh, India, Nepal, Pakistan and Sri Lanka) and five studies were conducted in Canada, USA and UK with migrant South Asian women (n = 135). Participants ranged in age from 15–49 years.
Themes From The Review
Thematic synthesis of the articles revealed three themes (1) I was afraid to share (2) They just walk away, and (3) Understand and listen to my pain. All three themes related to experiences and expectations of FV survivors that prevented them from seeking help from HCPs. Issues affecting disclosure included embarrassment as well as fears about confronting honor of family and concern by survivors that they would not be helped. Finally, women expected their suffering to be understood by HCPs who they wanted to be aware of how FV is conceptualised and responded to within South Asian culture.
Themes
I was afraid to share
Thirteen studies highlighted considerable ‘silence’ pertaining to sensitive social and health concerns, which appeared to be linked to stigma, family and community influence, loss of privacy owing to continual presence of family, and fear of the consequences of disclosure. (33–45). Women stated that fear of jeopardizing family honour and perpetration of violence as an entitlement of the husband were the main reasons for being afraid to disclose FV (35, 43, 45). Women felt embarrassed, guilty and ashamed of revealing the issue and taking action to put the family unit at risk (42).
“I told the doctor about how I noticed the bleeding the previous night. I just could not bring myself to tell the doctor about my husband hitting me in my stomach (during pregnancy). After all, my husband is still my husband and I did not want him to be in trouble. I felt very scared and ashamed to tell a stranger about my family problems. The thought of sharing such problems with my doctor was very shameful and embarrassing” (9), [Interview, United States].
‘‘If I protest I’ll be marked in the society and then my daughter wouldn’t be able to get married. If I voice my protest the community will blame me for not bearing it in silence. This helplessness is a torture in itself.’’ (45), [Interview, Bangladesh].
Community and family influence and pressure served as one of the main barriers to disclosure. Woman reported seeing HCPs for physical and psychological effects of FV, however they did not reveal FV for fear of being affronted by the community should the community find out about their disclosure (38). Women stated that they would conceal the cause of injuries sustained during FV to protect the family from stigma associated with FV (40).
“Maybe one and a half years ago [I noticed the pain]. My husband threw me against the wall. He hit my head hard on the wall. From that time there is pain all over my head.. .. The doctor asked me [if my husband hurt me]. We told him that I fell down and it happened [my mum told me to say that I fell by accident]” (40), [Interview, Afghanistan].
“He [my husband] once grabbed my hair and pulled my neck back – I couldn’t move my neck. At the hospital, my mother-in-law told them that I had fallen down the stairs” (35), [Interview, England].
Lack of privacy and confidentiality was another critical barrier for nondisclosure if women were not meeting with the HCP alone. Due to the lack of privacy and confidentiality, these women could not express themselves freely (38). The constant presence of husband and family members during medical consultations muted women’ ability to disclose their experience of abuse and seek help (41).
“I was scared because of my mother in law, she was there with me, if doctor ask her about it then, I will be caught up by both of my husband and in law…so I didn’t share” (41), [Interview, India].
“I was hesitant to talk because my elder son accompanies me for my hospital visit. I embarrassed to speak infront of him” (41), [Interview, India].
Women also showed fear of being confined to their houses by their husbands if they came to know about the disclosure of FV, and they were concerned that this would lead to them not being able to visit the hospital for follow up treatment resulting in their abandonment (41).
“I did not know anyone. I went to the doctor only once because of the swelling (from abuse). But I did not tell them [HCPs) what it was. And he [the perpetrator] would never take me to the doctor, whatever he did” (9), [Interview, United states].
Women stated that in South Asian culture, seeking help from formal health institutions was not feasible; they were frightened that to do so could be counterproductive and increase FV risk (33). Women thought that it would increase their risk of further violence instead of reducing it (41).
“I was actually scared because if he [husband) comes to know after confronting with him…… then I am gone forever… (uhh)….he will beat me like anything after going home” (41), [interview, India].
“I told all this [about the abusive relationship] to my doctor and told him not to tell my husband. If he comes to know, he will kill me. Doctor promised me he wouldn't tell my husband anything” (9), [Interview,United states].
Another fear mentioned by migrant South Asian women was being left alone after disclosing FV, with social and financial dependency on the husband necessitating silence (42). The women who were suffering were terrified that if the authorities arrested the abusive spouse, they would be left in a fragile financial situation, unable to sustain their families (38).
“They [HCPs] said it might be a police case, and if I said that I had been beaten by my husband, they would call the police. I would be left alone. I would not have any place to go. I lied and told them that I fell from the ladder while I was carrying a tub... I did not tell anyone” (38), [Interview, Nepal].
In conclusion, South Asian women hid their experiences of family violence from health care providers, choosing instead to live with the burden because of their fear of abandonment, family dishonor, and stigma associated with disclosure. Overall, the data demonstrated that the majority of the women prefered to conceal their abuse from healthcare practitioners out of fear of social stigma and shame. Furthermore, families of origin and in-laws play an important part in the FV process. Women were afraid of reprisal from their spouses were they to find out about the revelation of violence. Women's lack of autonomy made it much more difficult for them to take action against assault.
They Just Walk Away
Eleven studies reported that women showed minimal intention to use health services for help due to judmental atittudes of HCPs. They reported that firstly HCPs did not ask them about FV, and when they were asked, they came across an insensitive, judgemental and blaming response. Only one study found that women's reactions to reporting FV to HCPs were mostly encouraging (9, 33–35, 37, 38, 40, 41, 43–45) Women stated that they did not disclose their experiences of FV as they did not feel empathy from the HCP. Women also perceived that HCPs could not help to change their abusive situation (38).
“A woman [I knew] disclosed to the HCPs about being abused [raped] and that she did not want the baby because the child had no father. The HCPs were afraid that she would run away from the hospital without paying the bill and did not let her go. Nobody sought a solution. That is why I never say anything”(37) [Interview, Pakistan].
“I will never tell a health worker especially nurses because they have their own way [of dealing], they just walk away” (38), [Interview, Nepal].
While describing the perceived worries of contacting health institutions, one survivor woman said that the doctor did not assist with referral to a FV service (9). Women believed that the HCPs did not adequately advise and inform them concerning support services and follow-up (9, 38). Women highlighted that HCPs often failed to understand the root cause of their suffering. They stated that while looking at the women's presenting issues and health symptoms, they should consider the reason or person causing the problem (34).
“I haven't received any help ... I meet them [the social workers] every week. But I'm not getting any help from them. They just come and talk to me.” (9), [Interview, United states].
Women in the studies thought it would be ineffective to disclose FV to HCPs. As women had no one to safely share their expereince with, they described FV as a situation for which no practical choices exist (43). Despite barriers, women struggled to approach services to find the help they needed to leave the violent relationship, often repeatedly (35). One women managed to talk about sexual violence to HCP and asked for help to stop sexual violence against her but she was disoppointed with the HCP’s judgemental and insensitive response (38):
“Then he told me that I should talk to my husband and it was my responsibility to convince my husband. He used words like maybe you also need sex. I felt very bad because he talked to me like that. He was a male doctor” (38), [Interview, Nepal].
“I couldn’t talk about the sexual abuse as I was too embarrassed. … I started getting headaches and taking paracetamol. Eventually I told the doctor a bit about what was happening at home. He said, ‘Don’t think about it.’ But I say, how can I not think about it?” (35), [Interview, England].
Findings of this synthesis show that despite a number of obstacles, South Asian survivor women had made efforts to access health care services to find support. However, their experiences of services remained highly inconsistent and variable (35). In contrast to the studies canavased so far in this theme, one study found that many women reported that mental health providers responded empathetically to their disclosure of violence and they were provided support. Information about support services and legal options was provided to them to help them protect themselves and their children from further abuse. (41). They made comments such as:
“She listened patiently to what I said,” “she was supportive and gentle,” “he allowed me to speak,” “told not to hide these issues and encouraged me to seek help from my parents/friends,” and “she instilled confidence in me” (41), [Interview, India].
Understand And Listen To My Pain
Six studies reported how South Asian women shared what they wished from the HCPs, which included an opportunity to discuss their experience and get support and help from HCPs (34, 36–39, 41). Across the studies, South Asian women who experienced FV expressed support for FV screening, as long as it was private and confidential, and HCPs were nonjudgmental in their provision of safety and support (41).
“I told you [interviewer] because you seem to understand my pain’. Women said that empathy, politeness, love, and respect would motivate them to share their experience of DV. ‘... They [HCPs] should ask about what had happened to us, how we got to the hospital, who abused us’, said one of the women” (38), [Interview, Nepal].
Women suggested that HCPs should inquire about FV in culturally appropriate ways, inquiring about mental and social illness, including FV, during the routine consultation (37). Further, they reported that routine enquiry about FV could reduce the stigma and shame associated with it (36). According to women, speaking with their HCPs about their experience of violence would be beneficiat, as they might be able to provide general care and support to reduce their pain and stress (37).
‘If one has some grief, sharing with someone lessens the grief, though it may not solve the problem, but releases stress” (37), [Interview, Pakistan].
“They should use questions in a way that are focused and clear” (37), (FG, Pakistan).
“Do you have any tension? How is your home environment? How is your husband and your family- in- laws behaviour with you?” (37), [Interview, Pakistan].
Two studies looked at migrant South Asian women who stated that they are mostly just assigned to South Asian HCPs because they have the same cultural background. The assumption is that South Asian HCPs will understand and respond to FV survivors more appropriately. However, South Asian women themselves did not mention that they had received more support and care from HCPs who shared their cultural background (Puri 2005).
“Look, just because I’m Muslim and my GP might be Muslim, it doesn’t mean he or she is going to understand and help me! For all I know, they might give me a hard time for wanting to leave or saying anything at all about my husband. It’s a fairly big jump, isn’t it, to say that Asians will always support and understand Asians, right?” (39), [Interview, United Kingdom].
Women suggested that it would be useful to talk to their HCP if they are under stress and not feeling well, as the HCP might be able to provide some support and guidance (46). Most women wanted HCPs to inquire about women’s social health and wellbeing during routine comsultation, however, women’s expereince was of a lack of enquiry from healthcare practitioners regarding emotional health (37).
‘They ask in detail about me, about my diet and medicines, they take a complete history and ask about all my previous deliveries, but they never ask about my family environment or mental health” (37), [Interview, Pakistan].
South Asian women expected health care providers to be sympathetic to survivors of family violence, inquire about their experiences, ensure confidentiality and privacy, and refer them to appropriate services. Supporting and identifying these women could lead to better services for them.