Author: crhesi

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Why we Need Trauma- and Violence-Informed Maternal and Child Health Services: New Research from Rwanda and Local Implications

Aimable Nkurunziza, PhD Candidate (Nursing, Western University) and Berman Family Graduate Award Holder ankurun@uwo.ca

Dear reader, please take care when reading the following blog as it refers to issues of sexual and other forms of violence.

Photo by OWUROOLA ADEWALE on Unsplash

Trauma- and violence-informed care (TVIC) recognizes the intersectional impacts of structural inequalities, violence, and traumatic events, emphasizing both historical and ongoing violence. This approach emphasizes how a person’s past and present experiences of violence have shaped them, so problems are viewed as rooted in both their psychological and social conditions.

This sets the stage for why Rwanda is an important case study, given both the collective trauma of the 1994 Genocide against the Tutsi, and the gender-based violence (GBV) that was (i.e., genocidal rape) and is still so prevalent there, as it is here.

These observations are based on my PhD thesis exploring the experiences of adolescent mothers in perinatal services in Rwanda. From December 2021 to March 2022, I interviewed 15 adolescent mothers, 12 nurses and midwives, 12 community health workers (CHWs), and seven key informants (heads of health centers and supervisors of CHWs). I also reviewed two relevant documents that guide professional practice in this area.

Adolescent Mothers: Complexities and Challenges in Rwanda

Although Rwanda has made significant social and economic progress since the 1994 Genocide against the Tutsi, adolescent pregnancies, accounting for 5% of all pregnancies, remain a significant concern. Adolescent pregnancy is considered deviant and shameful in Rwandan culture, and indeed criminalized, thus young pregnant women and girls are often abandoned by the men who impregnated them, and face rejection from families and friends, stigma from the community, and increased rates of domestic violence.  In addition, over half of these pregnancies are the result rape. All of these factors increase the risk for mental health problems among these young women and girls, including high rates of depression and posttraumatic stress.

Violence and Inequities Affect Adolescent Mothers in Rwandan Perinatal Services

Perinatal nurses and midwives support adolescent mothers from antenatal care to the post-partum period and in subsequent child health services. However, to obtain services, a yearly fee of 3000 Rwf (almost $4 CAD) is needed for a health insurance card. Although low by Canadian standards this is out of reach for many Rwandan young mothers, especially if they have been ostracized by their families. So, when these young women and girls first go to a health center, for example when they learn they are pregnant, staff ask them first for their health insurance, which they usually do not have. Whether they receive further care varies; in extreme cases they will be sent back to their village where a leader will need to confirm that they can not afford insurance. The further shame and stigma of this process is an added form of systemic violence and trauma for adolescent mothers.

In addition, at the first pre-natal visit, every woman is required to bring her partner to be tested for HIV. For adolescents, especially those who are pregnant due to sexual assault, these requirements can be extremely (re)traumatizing. Those whose partners abandon them also indicate that hearing a nurse or midwife call the man who impregnated her “a father or husband” is harmful, given his lack of support. Healthcare professionals’ stigmatizing attitudes, disrespectful maternity care and even abuse towards adolescent mothers have been reported in Rwandan health facilities. In other research, only a few nurses and midwives (14%) reported that they were equipped, in antenatal care services, to take care of a client exposed to violence.

Because of these past and ongoing structural and interpersonal forms of violence, and their traumatic effects, pregnant adolescents in Rwanda often feel unsafe in the perinatal environment and sometimes lose trust in healthcare professionals. Others show signs of re-traumatization; a fact which healthcare professionals may not be trained to recognize or respond to. Most professionals try their best to support pregnant adolescents, including teaching and advocating for them, but lack of training and recognition of these issues in health services contexts make this very challenging.

Vicarious Trauma

Vicarious trauma, the harmful effects on providers of hearing stories of violence and abuse among their young patients, is also a concern. Providers may feel immediate emotional responses, and/or they may carry this burden out of the workplace, or, as I found in some of my data, even start to project what happened to those adolescent mothers to their own children, such as by being more protective or not allowing dating relationships. Most of these healthcare professionals do not know how to take measures to mitigate vicarious trauma, and their organizations do not provide needed supports. Therefore, incorporating Trauma- and Violence-Informed Care (TVIC) in Rwandan perinatal services would benefit pregnant and mothering adolescents, healthcare professionals, other perinatal clients, and health and social care systems.

Adolescent Mothers in the Canadian Context

In Canada, teen mothers face challenges similar to Rwandans when mothering; for example, researchers at the University of Alberta found that teenage mothers suffer from abuse and postpartum depression much more than their older counterparts. A study conducted at the Lawson Health Research Institute along with Brescia University College in London, Ont. revealed that teen mothers are more likely to live in poverty, suffer from poorer mental health, and use drugs more frequently. All these factors shape how teen mothers access and utilize perinatal services.

However, nurses and doulas also report disrespectful care and alleged mistreatment in childbirth, which can re-traumatize pregnant adolescents with potential histories of trauma who are experiencing violence. Access can be even more difficult for some; for example rural adolescent mothers find it especially difficult to access resources, with  one study highlighting negative stereotypes among these young mothers. Another study reported stigma and social isolation.

Integrating TVIC strategies in perinatal and other adolescent services will ensure physical, emotional and cultural safety and respectful, compassionate care to the benefit of young mothers, staff and entire organizations.

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Evolving a More Socially Conscious Medical School Curriculum

by Hooria Haider, Western University, Commuity Engaged Learning student, Health Sciences, Honours Specialization in Health Sciences with Biology

Photo by Pawel Czerwinski on Unsplash

THE PROBLEM

“Racism is often manifested with more subtlety than violent verbal or physical attacks. It can be implied through actions as well as attitudes and through a lack of consideration to such things as safety and comfort of others deemed undeserving”[1].

In the age of re-examining the structures, policies and frameworks that our political and social safety nets and services are built on, there has been a newfound focus on medical education. Healthcare is a vital service that every Canadian has an equal right to, however, as we become more conscious of implicit bias, and microaggressions in healthcare settings, there is an immediate need to proactively address these issues at the earliest steps of healthcare professional training. Thus, in order to create a new generation of physicians who provide equitable and culturally safe care, in recent years, medical schools have started to implement a more thorough and stakeholder-informed curriculum. Because this is a relatively new development, studies and new seminars and programs are continuously being implemented, evaluated and updated.

“Formal medical school curricula often espouse the value of equity, yet the hidden curriculum unfortunately sometimes conveys discrimination and unfair treatment,” says Michael Devlin, MD at Columbia University Vagelos College of Physicians and Surgeons[2].

WHERE ARE WE AT?

In light of newfound attention to this truth, efforts in Canadian and American Medical schools have started to actively incorporate an EDID curriculum, that is, curriculum that provides students with active strategies on how to approach problems, recognize bias/ microaggressions, deliver equitable care and uphold equity, diversity, Inclusion and decolonization (EDID).

In researching some of the studies done and curricula starting to be implemented in medical schools across Canada and the US, I have found some promising work. One school created a case-based curriculum following a communication framework to teach students to identify RDM (racism, discrimination, microaggressions) in both the relationship between medical professionals and also between physicians and their patients[3]. Evaluation of this curriculum found that it yielded positive results as student reported feeling empowered and more equipped with tools to address RDM when they face it in clinical situations. In addition to this, there has been an added effort to hear the voices of those who experience inequity in healthcare in Canada. One notable example of this is ‘The Indigenous Health Specialty in Postgraduate Medical Education (PGME) Steering Committee Education Guide’[4]. This is an in-depth document created by the Royal College of Physicians of Ontario and informed by a committee of Indigenous leaders, scholars and educators. This guide provides strategic guidance on how to implement Indigenous health pillars into curriculum and how to engage Indigenous partner organizations in an effort to decolonialize the healthcare sector as a whole. Additionally, this document provides insight into what Indigenous peoples need from physicians and explains the many roles and responsibilities of a physician when treating their communities.

FINAL THOUGHTS

After my glimpse into the growing literature and efforts towards EDID in medicine through tackling curriculum, I have come upon mixed feelings. Indeed, research regarding the inequities themselves is booming and coming into the light; topics such as implicit bias, disability studies and decolonization in a healthcare context are becoming common subjects of studies and learning programs. However, what is being done with the burgeoning research appears to be experiencing a lag in the process of being incorporated into mainstream medical curricula. The field feels as though it is in a perpetual state of workshopping, and has not yet reached the operationalized curriculum stage.

My hope is that the field of active implementation of the EDID curriculum in medical school continues to grow faster and becomes a more mainstream principle of the profession from the very beginning of training, or even when assessing medical school applicants. In the end, a dichotomy appears in my feelings: I am proud and hopeful for the work being done, but remain, in a sense, unsatisfied and anticipatory of an increase in actual action taken, policies implemented and syllabi altered with this research.

[1]Phillips-Beck et al., “Confronting Racism within the Canadian Healthcare System: Systemic Exclusion of First Nations from Quality and Consistent Care,” International Journal of Environmental Research and Public Health, 17 (2020): 3, https://doi.org/10.3390/ijerph17228343

[2] Kalter, “Navigating the hidden curriculum in medical school” AAMC News. (2019), https://www.aamc.org/news-insights/navigating-hidden-curriculum-medical-school

[3] Neves da Silva et al., “What Happened and Why: Responding to Racism, Discrimination, and Microaggressions in the Clinical Learning Environment,” MedEdPORTAL(2022), https://doi.org/10.15766/mep_2374-8265.11280

[4] Royal College of Physicians and Surgeons of Canada, “Indigenous Health,” (2022), https://www.royalcollege.ca/rcsite/health-policy/indigenous-health-e

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EQUIPping London’s Health and Social Services for Equity

This 4-part series explores substance use stigma and the ways that health and social service providers can improve care. The series includes:

  • Substance Use Stigma and Discrimination & the EQUIP Pathways Project
  • Finding Pathways to Substance Use Health:  The EQUIP Equity Action Kit
  • Equity in Action: London InterCommunity Health Centre
  • Equity in Action: More local EQUIP implementation

This link will take you to a page with a full list of the articles in the series.

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ACADEMIC MEMBER(S) – CHRESI EXECUTIVE COMMITTEE Call for Expressions of Interest

Deadline extended to September 09th, 2022

About CRHESI

The Centre for Research on Health Equity and Social Inclusion (CRHESI) is an interdisciplinary, collaborative initiative led by the Faculty of Health Sciences at Western University that provides a forum for research-enabled, synergistic and catalytic change for London and surrounding areas.

CRHESI’s research theme areas include: 1) Poverty and inequality; 2) Discrimination, violence and marginalization; 3) Working conditions/employment security; 4) Legacies of colonialism and contemporary realities; and 5) Health policy and services. Various theories and methodologies are used to examine questions of community and scholarly importance within and among these thematic areas.

The Centre is co-led by a community and academic co-director and supported by two part-time staff, with additional support from the Faculty of Health Sciences. Located at Innovation Works on Kind Street in Downtown London, CRHESI is comprised of over 250 community and university partners. For more information, see: https://crhesi.uwo.ca/about-us/

CRHESI’s Executive Committee

Comprised of the Community and Academic Co-Directors, and a balanced mix of Western University faculty representatives, community agency representatives, and Western University student(s)/emerging researcher(s) appointed to 2 or 3-year terms, the Executive Committee sets operational priorities, provides oversight for strategic planning, and problem-solves as issues arise; further, it provides advice and support regarding: project activity development and implementation; fostering new research collaborations; community-university relationship development; assessing and monitoring the allocation of resources.

The Committee meets quarterly, generally at Innovation Works, with additional activities conducted via CRHESI events, projects or email consultations, as needed. Pre-meeting packages are sent approximately one week in advance. Terms of Reference are available on request.

This position is uncompensated, though expenses to attend meetings are covered.

For more information about current members, see: https://crhesi.uwo.ca/about-us/governance/

Academic Member Eligibility

Academic Executive Committee members are those with continuing faculty (tenure or non-tenure track) appointments in any Western University Faculty or School. Members should have interest and expertise in one or more of the CRHESI theme areas as demonstrated through relevant funding, publication and/or knowledge mobilization activities.

Expressions of Interest

To indicate interest in joining CRHESI’s Executive Committee as an Academic representative, please send a 250-word document outlining your relevant experiences and expertise, and what you would hope to contribute to CRHESI’s work and a more equitable and inclusive London community, along with a current CV, to info@crhesi.ca by September 09th, 2022.

These expressions of interest will be reviewed by CRHESI to assess fit to our mandate and our current committee composition and needs. A meeting with top candidates will be requested, and a final decision is anticipated in September 2022, with the person attending their first meeting in November 2022.

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Cultural Humility

CRHESI co-coordinator James Shelley blogs about the concept of ‘cultural humility’… and the perspective it sheds on the idea of ‘cultural competency’:

Applied to healthcare in a cross-cultural context, we might imagine that a true master of cultural competency would be the last person to think of themselves as a ‘master’ at all. In fact, such a person might be hesitant to even self-describe themselves with the word ‘competent’. ‘Competency’ suggests a certain level of achievement, but an appreciation for the subtleties and prevalence of culture leaves one ever-questioning their ideas about what ‘the other’ person — the patient, for instance — truly needs, wants, and believes.

Read the full blog post here.

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