Paramedic-Conducted Mental Health Counselling for Abused Women in Rural Bangladesh: An Evaluation from the Perspective of Participants

Article excerpt

INTRODUCTION

Nowhere in the world is gender imbalance more present than South Asia. Violence against women is a pervasive problem in this region (1). In addition to physical violence, South Asia documented the highest rates of sexual and emotional violence against women.

A population-based study conducted in 2001 in Bangladesh by ICDDR,B and Naripokkho--a women's activist organization--as part of a World Health Organization (WHO) multi-country study on violence against women (VAW) found that two in every five women had been physically abused by their husbands in both rural and urban areas of Bangladesh (2). Sexual violence within marriage was even higher in rural Bangladesh with every second woman reporting sexual abuse by her husband (3). Emotional violence by a husband was reported by 44% of urban women and 31% of rural women (3).

Evidence on negative consequences of physical and sexual violence on mental health of women is abundant in literature. Results of studies in North America showed that depression and post-traumatic stress disorder, which have substantial comorbidity, are the most prevalent mental health sequelae of intimate partner violence (4-11).

The developed world generate most literature on consequences of violence against women. A few studies conducted in developing countries on this issue basically substantiate the findings from developed countries. For example, 70% of emotional distress cases in Nicaragua was attributed to intimate partner violence (12), and 72% of physically-abused women in Pakistan were suffering from depression and anxiety (13). In Bangladesh, results of the ICDDR,B-Naripokkho study suggest an association between physical violence by husbands and mental health problems in women ranging from functional disorders to suicidal intention (14) and attempted suicide (3). Moreover, it indicates a dose effect of the frequency and severity of physical abuse on the level of emotional distress of women.

The majority (66%) of urban and rural women in Bangladesh never discussed their experience of spousal violence with anyone (2). Sixty percent of urban and 51% of rural abused women never received any help in addressing violence. Only 2% ever sought help from institutional sources, from where support was not forthcoming.

Although mental health counselling services are effective in increasing the efficacy of abused women, strengthening the coping skills of women, and enhancing their decision-making ability in other settings (15-20), so far mental health of abused women has remained an area inadequately addressed by any policy or programme in Bangladesh. Counselling expertise in the area of domestic violence has only begun to be developed in Bangladesh, and currently, only a few mental health counsellors in the country have been trained in counselling of abused women. These counsellors are mostly city-based. Even the government initiative to provide some mental health services to abused women through One Stop Crisis Centres are based in divisional hospitals only. Thus, a huge imbalance exists between the available supply and the need throughout the country, particularly in rural areas. Given the resource constraints making available, a team of professional counsellors providing services to abused women throughout Bangladesh does not seem to be practical.

In this scenario, in 2001, ICDDR,B became part of an initiative for developing a group of counsellors for providing service to abused women in Bangladesh. Counselling was provided to abused women as part of a larger study known as Maternal and Infant Nutrition Interventions in Matlab (MINIMat). The MINIMat study enrolled all pregnant women in Matlab from 2001 to 2003. The questionnaire on violence was administered at the clinic-visit during 30th week of gestation. A modified version of conflict tactic scale (CTS) was used for exploring exposure of women to violence (21). The self-reporting questionnaire with 20 items (SRQ-20) developed by the World Health Organization was used for measuring mental stress. …