Why We Don’t Screen for Intimate Partner Violence in Sub-Saharan Africa… and Why We Must

In my own experience testing an Intimate Partner Violence (IPV) screening intervention in Kenya, I have found that every one of the great reasons not to screen is critically important to consider. But in the course of my work on this issue, I have also found 111 reasons why screening for IPV cannot be brushed aside, either.

There are legitimate reasons why we shouldn’t bother screening for—that is, asking a few key questions to identify survivors of—intimate partner violence (IPV) in sub-Saharan Africa. Our public health systems are weak. Our providers are swamped, working under difficult conditions, and thus lack the capacity to offer basic support to survivors. We still need to sort out our referral systems. We need to make sure we have the resources to protect clients’ confidentiality. What if our health providers have poor attitudes about violence or simply aren’t willing to screen? What if clients don’t want to be screened? What if we find out that violence is totally normalized in our context? Who are we to redefine something as deplorable and to screen for it just because we think it is? Or what if, by screening, we end up opening up a can of worms that we can’t shut? Besides, the World Health Organization is on the verge of recommending against (universal) screening, as it has apparently not been found to be terribly beneficial in “resource-rich” parts of the world; so why should we bother?

And so, while IPV screening has been going on in some other parts of the world for decades, in sub-Saharan Africa, we have only just begun to sniff suspiciously around this issue. To try and figure out if it’s even worth it, given the grim realities. We’re unfashionably late to the party (but at least we made it).

As we observe 16 Days of Activism Against Gender Violence, from 25 November to 10 December, I have been thinking about the cases for and against screening for intimate partner violence. In my own experience testing an IPV screening intervention in Kenya at Kenyatta National Hospital (KNH)—the oldest, largest national referral hospital in the East African region—I have found that every one of the great reasons not to screen is critically important to consider. This discovery came as no shock to me. We do not live in a perfect world.

But in the course of my work on this issue, I have also found 111 reasons why screening for IPV cannot be brushed aside, either. These reasons are personified by the 111 women we have interviewed over time at KNH to try and figure out whether screening is a good idea: women who had simply come in to different clinics for their medical appointments, and who graciously took the time to share their thoughts about IPV screening with us.

One woman in particular stood out. I would describe her as one of the ‘lucky’ ones—a survivor who found out about the Gender-Based Violence Recovery Centre at KNH not through screening, but by sheer chance. From her perspective, commencing an IPV screening intervention at the hospital was “a very important move.” She told us:

“If I had someone who had asked me such [screening] questions, then I wouldn’t have suffered for that long like I did. I used to come here [KNH] all the time for treatment, but nobody ever asked me anything. I would come here for treatment after my husband had beaten me. I’d be treated and then I’d be told to go home. Sometimes, my husband used to box me in the head; and so, some women [have] injuries in the head but they have no physical symptoms to show [this].”

Clearly, there are reasons why screening does matter—even in sub-Saharan Africa, even with all the undeniable limitations.

What I am learning through implementing this IPV screening initiative with women is that, sometimes, all that stands between a survivor and the help she needs are a few simple questions. I’m learning that a few simple questions don’t take an inordinate amount of time for health providers to ask. I’m learning that health providers themselves are frustrated because they realize that IPV is a large contributor to the health conditions that their clients experience, and that if we addressed IPV we would save everyone’s time (and money) and get to the root of a good number of health problems.

I’m learning that screening is a stealthy and effective means of creating awareness around IPV, of advocating for women, of de-normalizing an issue, of letting the world know that an issue is serious, of letting the world know an issue has dire health implications. I have learned that once providers are sensitized about violence, they truly begin to care (and what is the medical field about, if not caring?). Frighteningly, I am learning that if we don’t ‘work out the kinks’ involved in screening adults, we will never (for ethical reasons) get round to screening children—even though we know full well that many survivors of sexual violence seeking services in sub-Saharan Africa are below the age of 18. In not bothering to screen, what we’re essentially saying is that our children can wait; our children can live with this. 

I suppose the most important reason why we should screen for IPV, from my perspective as a qualitative researcher, is because, qualitatively speaking, an ‘n’ (or sample size) of 1 is significant. 

To me, violence is a lot like tuberculosis. A single, confirmed case of TB is attended to with a level of seriousness that acknowledges the many more cases that a sole case really represents. That’s what a single case of IPV represents: many more cases. IPV has its effect on the survivor, the perpetrator, the children who witness it (and who perhaps even experience abuse themselves), and many others.

Based on my own efforts in testing a screening initiative, I do not recommend that we screen for IPV everywhere. I do recommend, though, that we don’t throw the baby out with the bathwater. There are certain settings in which screening for IPV does make sense—and they don’t all have to be places with a specialized sexual and gender-based violence clinic on-site. Referrals work for some survivors who are desperate enough for help.

Screening for IPV and connecting those identified to services (whether immediately on-site or through a lengthier referral process) can be of immense benefit to those affected directly and indirectly. 

We just have to work out the kinks.

I dare us to try.