Nearly one in three women worldwide experience physical or sexual violence from an intimate partner over their lifetime, according to data from the World Health Organization. As Dr. Amira Shaheen learned, the numbers were the same in her native Palestine.
But as often happens in public health and epidemiology, the numbers don’t tell the full story.
While some countries have robust support systems for victims of gender-based violence (GBV), and laws that require health professionals to report suspected abuse, that’s not the case in Palestine. To compound the problem, societal norms mean that many women will not report abuse.
“We found out that women don’t want to leave their husbands – they want to keep their family together,” said Amira, Assistant Professor of Epidemiology at An Najah National University (ANNU) in Nablus, West Bank. “And part of it is because society does not look (favorably) on women who are divorced, so they didn’t want to be labeled as divorced.”
Amira knows this because she has interviewed many women in this situation. It’s part of a research project she has undertaken to enhance primary healthcare’s response to violence against women.
Peer-reviewed publications on GBV in Palestine are limited. The only survey, published in 2011 by the Palestinian Central Bureau of Statistics (PCBS), indicated that the prevalence of married Palestinian women who were exposed to any type of violence was 37 percent, which is is inline with global statistics.
Taking her knowledge out of the lab
Dr. Shaheen has always had a passion for science, but her path took a sharp turn after she completed her bachelor’s degree in chemistry and chemical technology.
“I studied chemistry because I loved this subject, so I went to university and studied it for four years,” she said. “And then I found out, well, studying chemistry can answer many questions, but I don’t want to spend my time working in laboratories. I decided I would love to work with people – to know what health problems people are facing and how they can be helped.
Her desire to work with people led her into public health, with a focus on issues in her country. For her first project, she drew on her background in chemistry. Because farmworkers in Palestine were using excessive pesticides, she teamed up with Prof. Yehia Abed to explore their knowledge, attitude, practices and toxicity symptoms, publishing their findings in The Lancet.
Later, she was drawn by a problem that’s prominent among the young population of Palestine: injuries. For her PhD thesis at the London School of Hygiene & Tropical Medicine (LSHTM), Amira investigated the epidemiology of unintentional injuries among Palestinian school-aged children, basing her study on mortality data from the Palestinian Ministry of Health and morbidity data from a project on health behavior in school-aged children (HBSC). She published her research as lead author in the WHO’s Eastern Mediterranean Health Journal: “Flying bullets and speeding cars: analysis of child injury deaths in the Palestinian Territory.”
After receiving her PhD in 2009, she stayed on to work at the LSHTM and the Center for Evidence Based Medicine at the British Medical Journal (BMJ).
In 2011, she returned to Palestine, where she has been teaching at ANNU and doing research. Amira is currently the principle investigator on a project called HERA: Healthcare Reponding to Violence and Abuse – a collaboration between ANNU, University of São Paulo in Brazil, University of Bristol, LSHTM, and the World Health Organization.
Locally, Amira collaborates with the Ministry of Health in Palestine and Juzoor, along with her ANNU colleagues Dr. Abdulsalam Alkaiyat and Suzy Ashkar, and the support of Prof. Maher Natsheh, President of the university. As part of HERA, they have implemented an evidence-based intervention called IRIS, Identification and Referral to Increase Safety. IRIS was developed by HERA lead Dr. Gene Feder, Professor of Primary Care at the University of Bristol. In Palestine, Amira and her colleagues have modified it to meet cultural norms.
“We considered the cultural sensitivity of GBV,” Amira said, “so in each of our study clinics, we allocated a female nurse as a case manager to work with these woman when violence was identified.”
HERA in Palestine
The HERA project in Palestine had three phases:
- Phase 1 was the formative phase were the views of the women survivors of violence, healthcare providers and officials from organizations working on gender-based violence were collected and presented in a stakeholder meeting. The views of people in this meeting were taken into account to develop a culturally accepted intervention.
- Phase 2 involved developing and implementing the intervention. Our intervention was based on training healthcare providers on how to identify and refer women exposed to violence.
- Phase 3 involved evaluating the intervention through exploring the views of the trainers, the women who were identified during the intervention period (6 months), and the healthcare providers.
While interviewing women for the HERA project, Amira noticed that these women were in need of psychological support. This support is centrally provided by the Ministry of Health, but most women cannot afford to go to these clinics.
Healthcare providers also raised the issue of psychological skills and their wish to be trained. Now, Amira and her colleagues are addressing this issue in a second project; in each of their targeted clinics, they seek to provide training for one or two healthcare professionals on principles of psychology. “By doing this, we hope to improve the health of battered women, where psychological violence is also prevalent in their relationships,” Amira said.
Taking the plan to policymakers
Amira and her team presented the primary results at an end-of-project conference on April 23. This meeting was attended by the key stakeholder in the field: representatives from NGOs working on gender-based violence, UN institutions that fund research on GBV in Palestine, the Ministry of Health and researchers with interest in the topic.
Amira said findings indicate a “lack of awareness” about the role primary health clinics could play in response to violence against women:
Women wanted the healthcare providers to initiate questions when they saw signs and symptoms of violence. They were disappointed when healthcare providers were only interested in doing treatment without asking about the violence they were exposed to.
Amira said officials in organizations that deal with violence against women highlighted the importance of the health setting as a first line for receiving these cases. They emphasized the importance of reducing the healthcare providers load to give them time to ask women about violence if they suspected it.
Healthcare providers, meanwhile, confirmed that they are overloaded with seeing patients – but they also expressed concern for their own safety. “They are reluctant to ask the woman if they suspect violence, fairing family retaliation,” Amira said.
Personally, Amira said she was moved by her experience with these women and the possibility of helping them.
“They affected me a lot,” she said. “Most of them, when I finished the interview, would ask me, ‘Are you coming back?’ Survivors of violence want someone to listen to them.”
An award takes Amira to Washington
In February, Amira was honored for her work with the 2019 OWSD-Elsevier Foundation Award for Women Scientists in the Developing world. As part of that award, she and the other four awardees met with official’s in US government to learn more about how science policy is developed.
“As an epidemiologist, winning the OWSD-Elsevier Foundation Award is further evidence of the importance of putting results into practice in the field of public health,” Amira said. “It gives me the courage to further research culturally sensitive issues, and it will motivate young health graduates to enter the field of public health.”
Advice for young scientists
In addition to her research, Amira teaches Public Health and Epidemiology at the university. “Through this course, I can empower my students,” she said. “Many young women go on to complete their (master’s) degree in public health because they love the course I taught them.”
Her advice to them stems from her own experience.
I advise them that you are the future of this nation, and you shouldn’t let the culture be your fate. You need to change this culture — you are educated in order to change this culture, so go out and change as much as you can.
As Amira uses her science to reform a single but crucial aspect of society, and as her research takes her to other countries and cultures, she has no desire to leave the place she calls home.
“Actually, I love Palestine,” she said, “and I love giving help to my people. These women I interviewed – they affected me a lot.”