ResearchPod
ResearchPod
A few words with… Professor Gene Feder OBE
In this International Women’s Day episode, we chat to Professor Gene Feder OBE, Professor of Primary Care at the Centre for Academic Primary Care, Bristol Medical School, about the Healthcare Responding to Violence and Abuse (HERA) programme.
For the past five years, HERA has been co-developing and testing women-centered and culturally-appropriate domestic violence and abuse (DVA) healthcare interventions in low-and middle-income countries – Brazil, Nepal, occupied Palestinian territories and Sri Lanka – with an aim to improve the rates of identification and reporting of DVA, and create more effective healthcare responses.
Professor Feder talks about the co-development of care models specific to each country, the outcomes and surprising findings of the study to date – and what working on HERA means to him as a health researcher.
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The National Institute for Health and Care Research (NIHR) Global Health Research Group was co-led by the University of Bristol and London School of Hygiene & Tropical Medicine. The Group reported their findings and published a PolicyBristol report in 2024
Read more about HERA on the University of Bristol Centre for Academic Primary Care webpage and the University of Bristol News page.
Professor Feder is Director of VISION, a UK Prevention Research Partnership focused on violence prevention.
00:00:10 Ruth Daniels
Welcome to this episode of a few words with our conversation series about our people and their work at the University of Bristol.
00:00:17 Ruth Daniels
I'm Ruth Daniels, part of the communications team, and today I'll be speaking with Professor Gene Feder, a professor of primary care at the Bristol Medical School, about the healthcare responding to violence and abuse study.
00:00:29 Ruth Daniels
Better known as HERA.
00:00:30 Ruth Daniels
We'll be chatting about what Hera means for women in healthcare systems in low and middle income countries five years into the program.
00:00:51 Ruth Daniels
Thanks very much for joining us today, this conversation.
00:00:54 Ruth Daniels
You know, I've read this stuff on the institute's web page and I've read the news piece.
00:00:59 Ruth Daniels
Speaking to you, it helps me understand the study so much better.
00:01:02 Ruth Daniels
That's great.
00:01:03 Ruth Daniels
Could you tell us a bit about the heritage, how it began and what it?
00:01:08 Ruth Daniels
To achieve.
00:01:09 Prof Gene Feder OBE
The.
00:01:10 Prof Gene Feder OBE
Study hair stands for healthcare, responding to violence and abuse.
00:01:14 Prof Gene Feder OBE
It also happens to be in the name of the Greek goddess that the wife of Zeus.
00:01:21 Prof Gene Feder OBE
Is essentially a program of research funded by the National Institute of Health Research in the UK as a.
00:01:28 Prof Gene Feder OBE
Health group.
00:01:30 Prof Gene Feder OBE
And it was a research study that was focusing on a more effective healthcare response to to domestic violence.
00:01:40 Prof Gene Feder OBE
By domestic.
00:01:41 Prof Gene Feder OBE
What I mean is abuse that you experience if you're a survivor.
00:01:47 Prof Gene Feder OBE
From your partner.
00:01:48 Prof Gene Feder OBE
Spouse or indeed another family member.
00:01:52 Prof Gene Feder OBE
And the Hera Project group developed from work that we've been doing in the UK around the healthcare response, developing programs for training doctors, nurses and other healthcare workers around.
00:02:08 Prof Gene Feder OBE
How to respond? How to identify patients who are experiencing abuse and how to support them and how to give them the kind of care they need?
00:02:19 Prof Gene Feder OBE
So building on that work in the UK, Hera collaborated with researchers in four other countries to try to work on a model that could make the healthcare response better in those countries as well.
00:02:34 Prof Gene Feder OBE
Particularly within primary and secondary reproductive health care services.
00:02:40 Prof Gene Feder OBE
Those four countries were Brazil, Nepal, Sri Lanka and the occupied Palestinian territories, working with universities in those countries, we put together a program of research.
00:02:55 Prof Gene Feder OBE
Which combined research about the needs within those countries and the patients and the health services and how best to respond, but also in each of them developing a model of care.
00:03:07 Prof Gene Feder OBE
Training and and referral.
00:03:10 Prof Gene Feder OBE
Which was specific to those countries.
00:03:11
Skateboard.
00:03:13 Prof Gene Feder OBE
And then pirating them to see where those models, those programmes, feasible or acceptable, was there a signal there that suggested they might actually be effective in improving outcomes for survivors of domestic violence?
00:03:27 Prof Gene Feder OBE
Was the question we were trying to answer over a three year, extended to almost four years because of COVID, research program in in collaboration with with researchers in those four countries.
00:03:44 Ruth Daniels
You touched on there about those different models of interventions that kind of women centered and culturally appropriate.
00:03:51 Ruth Daniels
What does this mean?
00:03:53 Prof Gene Feder OBE
My culturally appropriate, and this was.
00:03:54 Prof Gene Feder OBE
Learning that.
00:03:55 Prof Gene Feder OBE
Had out of the program.
00:03:57 Prof Gene Feder OBE
Is that you can't take a model.
00:04:00 Prof Gene Feder OBE
Care or training that.
00:04:02 Prof Gene Feder OBE
That matter from 1 country. Even if you show that it's effective and we actually developed a model within the UK called Iris for training and referral, which we put through a randomized control trial and actually showed that it was effective and cost effective.
00:04:18 Prof Gene Feder OBE
The idea that you can then take that and then transplant it into another healthcare which we never imagined we could do. But you know as a kind of an absurd example, well, obviously that's not going to work.
00:04:30 Prof Gene Feder OBE
Then the question is OK, what do you need to do to develop a program or intervention that is culturally appropriate for that healthcare system in that society so.
00:04:41 Prof Gene Feder OBE
An example.
00:04:42 Prof Gene Feder OBE
From Hera is that in countries around?
00:04:46 Prof Gene Feder OBE
World there.
00:04:47 Prof Gene Feder OBE
Different understandings of what domestic violence is.
00:04:52 Prof Gene Feder OBE
There's different laws, more or less explicit around the illegality of domestic violence, and that varies between those four countries that I talked about and therefore how you do your training and how you explain to doctors and nurses and other health care workers what domestic violence is.
00:05:11 Prof Gene Feder OBE
What it would be inappropriate response is going to have to vary and it needs to be informed.
00:05:18 Prof Gene Feder OBE
By your collaborators and by the stakeholders within those countries, whether those stakeholders are health service managers, whether it's ministries of health, whether it's the doctors union, you know all of those components need to be taken.
00:05:33 Prof Gene Feder OBE
On board, it really isn't about transplanting one model into another country, and we learned how to do that and by then submitting it to piloting, actually trying to do it and then measuring and evaluating through interviews.
00:05:47 Prof Gene Feder OBE
How?
00:05:49 Prof Gene Feder OBE
This could work.
00:05:51 Prof Gene Feder OBE
That's a hard test, but that was the whole point of the program.
00:05:54 Prof Gene Feder OBE
Have any illusions about assuming that it's just going to work?
00:05:59 Ruth Daniels
So the pilot studies have been running for the past five years and the National Institute for Health and Care Research Global Research Group recently published the findings so far.
00:06:08 Ruth Daniels
Could you talk a bit about the impact of Hurricane Dur?
00:06:12 Prof Gene Feder OBE
The impact which we're looking for and which it's still early days because the point about research is that often there's a long tail within which you're measuring and evaluating whether there's been any impact.
00:06:25 Prof Gene Feder OBE
It's.
00:06:26 Prof Gene Feder OBE
Relatively early days, but even though the program is over and.
00:06:29 Prof Gene Feder OBE
Been over for a year.
00:06:31 Prof Gene Feder OBE
We still seeing what the effect is.
00:06:34 Prof Gene Feder OBE
So the most important measure for us is whether in those countries the outcome of the pilot and if I could just say from what some of the outcomes are an important outcome is that in three of the countries.
00:06:49 Prof Gene Feder OBE
There was a marked increase in the identification of patients who were experiencing domestic.
00:06:56 Prof Gene Feder OBE
It's a kind of necessary, but not sufficient condition for doing anything in terms of supporting those people. And in this case, those women.
00:07:05 Prof Gene Feder OBE
So in Sri Lanka there was a 69% increase in identification, Brazil 78% in Nepal, 100% increase. In these small clinics like in Nepal, they were actually clinics in the countryside in the foothills of the Himalayas in Sao Paolo, Brazil. It was within.
00:07:22 Prof Gene Feder OBE
Quite tough inner city areas of.
00:07:26 Prof Gene Feder OBE
So in Sri Lanka it was also can rule areas. So these were, if you like, hard to reach areas and we did show that identification increased. Now unfortunately in the occupied Palestinian territories on the West Bank there was a decrease in identification. So it didn't work within that.
00:07:44 Prof Gene Feder OBE
And part of the point of our why I'm going to go back though to this question about what impact it has had so far. So the best judge of the impact for me would be within those countries where we did the piloting.
00:07:59 Prof Gene Feder OBE
Has there been some continuation of the?
00:08:03 Prof Gene Feder OBE
You know, because it's become embedded in the health care system.
00:08:06 Prof Gene Feder OBE
Now that varies from country to country.
00:08:09 Prof Gene Feder OBE
So in Brazil, in Sao Paulo anyway, it definitely has.
00:08:14 Prof Gene Feder OBE
In that, there's been great interest from the Municipal Ministry of Health, Department of Public Health in the program and in supporting it.
00:08:22 Prof Gene Feder OBE
So that has continued there in Sri Lanka, the model is still, I think working in this.
00:08:30 Prof Gene Feder OBE
Based in, but it hasn't necessarily translated at the moment into broader national policy, although we have a mechanism for doing that because the Ministry of Health specific focus on its gender based violence section really wants to take the findings and implement them. So, you know, to kind of.
00:08:50 Prof Gene Feder OBE
This space in.
00:08:52 Prof Gene Feder OBE
There has been a continuing of parts of the program and it's also influenced national policy, so these are.
00:08:58 Prof Gene Feder OBE
They're not overwhelmingly compelling evidence for impact yet.
00:09:04 Prof Gene Feder OBE
Because it's still early days and what we're really looking at is embedding within national policy and national services within the occupied Palestinian territories. The model really didn't work.
00:09:17 Prof Gene Feder OBE
And therefore the model therefore needs to be developed further.
00:09:21 Prof Gene Feder OBE
One of the reasons it didn't work, and this is particularly salient currently. I mean, we're talking now in January 2020.
00:09:28 Prof Gene Feder OBE
Is the West Bank is a very dangerous place and it's very difficult to get the kind of support to primary care centres because of the violence on the West Bank.
00:09:40 Prof Gene Feder OBE
So you know that was a key, an issue, violence.
00:09:44 Prof Gene Feder OBE
Around contextual violence was an issue also in Brazil and Sao Paulo, with drug cartels, so we didn't understand when we started how important that contextual aspect was, which needed to be taken into account.
00:09:57 Prof Gene Feder OBE
So I think in Palestine it's more about developing the model and also hoping that the situation becomes more stable where you can have innovation in the healthcare system.
00:10:06 Prof Gene Feder OBE
So.
00:10:07 Prof Gene Feder OBE
Long answer to a short question.
00:10:10 Prof Gene Feder OBE
What impact do we have so far? I think my short answer would be so far so good, at least in two, if not three, of the countries.
00:10:18 Prof Gene Feder OBE
But it's something that we do have to monitor.
00:10:21 Prof Gene Feder OBE
And one additional thing, in Sri Lanka, there's quite an appetite to expand the program and actually submit it to a randomised control trial, a cluster randomized trial, which is a strong sort of evidence for effectiveness.
00:10:35 Prof Gene Feder OBE
We look forward to supporting.
00:10:36 Prof Gene Feder OBE
Work in in relation.
00:10:38 Prof Gene Feder OBE
OK.
00:10:39 Ruth Daniels
When you talk about the context of violence within two of the countries, is that one of the most insightful or kind of surprising things to you?
00:10:49 Prof Gene Feder OBE
Yes, the finding around the importance of contextual.
00:10:53 Prof Gene Feder OBE
Societal violence, violence of occupation in occupied Palestinian territories was one of the surprising findings now.
00:11:04 Prof Gene Feder OBE
Looking back, why were we surprised about?
00:11:06 Prof Gene Feder OBE
Do you see what I mean? That there's a sort of it kind of seems.
00:11:10 Prof Gene Feder OBE
It's sort of when we were designing this, including with our collaborators that, you know, Co producers of this research.
00:11:16 Prof Gene Feder OBE
Church in San Paulo in the West Bank. We didn't really think about it. I mean, there is a danger with research on any violence between the best of our seeing it in a siloed way, when in fact, violence in society.
00:11:31 Prof Gene Feder OBE
Is part of a kind of complex system, and the domestic violence isn't separate from other kinds of violence.
00:11:37 Prof Gene Feder OBE
I'm an example from the Occupy paste and territories.
00:11:40 Prof Gene Feder OBE
That your likelihood of having perpetrating.
00:11:44 Prof Gene Feder OBE
Behaviour in your relationship.
00:11:47 Prof Gene Feder OBE
Is increased if you've been imprisoned. If your if your house has been destroyed. If you've had the kind of stressful, violent experience.
00:11:57 Prof Gene Feder OBE
Saying that's an excuse for domestic violence. It never is, but.
00:12:02 Prof Gene Feder OBE
These are.
00:12:03 Prof Gene Feder OBE
So we came into this study perhaps slightly naively not really understanding that. And out of the study, one of the most important findings is you have to think about the violence that's outside the family outside the clinic as well. If you're going to understand how best to respond.
00:12:22 Prof Gene Feder OBE
To domestic violence.
00:12:29 Ruth Daniels
Five years of full pilots.
00:12:31 Ruth Daniels
I guess it would be quite an expansive question to say what's next.
00:12:34 Prof Gene Feder OBE
Is a good question because it can be answered in different ways in relation to building on her research.
00:12:40 Prof Gene Feder OBE
Be split into a number of.
00:12:42 Prof Gene Feder OBE
One is what's happening in the individual countries and in each of them there is.
00:12:49 Prof Gene Feder OBE
An intention and also an outcome.
00:12:52 Prof Gene Feder OBE
To develop and evaluate.
00:12:54 Prof Gene Feder OBE
More in Sri Lanka, although this hasn't happened yet, I think there is this intention to run a cluster randomised trial around, not necessarily exactly the same as the hair intervention, but informed by the hair findings and also by.
00:13:09 Prof Gene Feder OBE
A pH. D.
00:13:09 Prof Gene Feder OBE
That was done as part of Hera in Nepal.
00:13:13 Prof Gene Feder OBE
Is.
00:13:14 Prof Gene Feder OBE
Work on national policy and developing the model, particularly in Nepal, as a strong Co produced element, really working with survivors and to take that model forward.
00:13:25 Prof Gene Feder OBE
In Brazil, there is an intention to do new research around the.
00:13:32 Prof Gene Feder OBE
Broader Hera work.
00:13:35 Prof Gene Feder OBE
And I guess also the further development model also in terms of psychological support.
00:13:40 Prof Gene Feder OBE
Now in the UK, here we're trying to.
00:13:42 Prof Gene Feder OBE
That so?
00:13:43 Prof Gene Feder OBE
Some of that is kind of bilateral.
00:13:46 Prof Gene Feder OBE
So we're kind of the researchers here and it's not just in the University of Bristol, it's also Co director of this group.
00:13:54 Prof Gene Feder OBE
Was Lorraine Backus, professor at London School of Hygiene, Tropical Medicine.
00:14:00 Prof Gene Feder OBE
And both within Bristol and within London, School hygiene, tropical Lshtm, we're trying to support those grant applications and that further research the concept is still one of Co production not of, you know, UK universities saying, hey, we know what needs doing and we're going to do it next.
00:14:17 Prof Gene Feder OBE
Is about working on that with our partners and these.
00:14:20 Prof Gene Feder OBE
So really valuable.
00:14:22 Prof Gene Feder OBE
Personally, I'm going to be involved in another Nitro global health group, which is led from Birmingham to try to develop more interventions that are culturally appropriate in women centres. So using some of the learning from Hera to do that.
00:14:41 Prof Gene Feder OBE
So I think kind.
00:14:42 Prof Gene Feder OBE
A short answer to the question about what's next is Hera has legs and legs are taking it into different projects which are very much partnership with researchers.
00:14:54 Prof Gene Feder OBE
And clinicians and service providers within those four countries.
00:14:59 Ruth Daniels
And lastly for you personally and professionally, what's been the best part of working on Harris?
00:15:05 Prof Gene Feder OBE
These wonderful relationships also now friendships with researchers in other countries who have exactly the same intention and goal that I have, which is to try to improve the way.
00:15:21 Prof Gene Feder OBE
Healthcare services and commissions respond to survivors of domestic violence and improving outcomes for those survivors and basically are stepping up to the plate and saying actually Healthcare is part of a societal response. For me that's been.
00:15:34 Prof Gene Feder OBE
Able to see the common aim with those other researchers, and also to learn from them about the importance, for instance, of community and Community support to this. You know the UK, we don't quite have that deeper understanding of how we have to engage with our communities around.
00:15:55 Prof Gene Feder OBE
Even around the healthcare response in the countries that we worked in, that was much more palpable and much more explicit it.
00:16:03 Prof Gene Feder OBE
So I've actually.
00:16:04 Prof Gene Feder OBE
Learned my secret thought here is I've learned more from my collaborators than they have learned from.
00:16:11 Prof Gene Feder OBE
They will probably deny that, but I think there's been this really very rich mutual learning around the same goal and that for me is my most important take away.
00:16:23 Ruth Daniels
OK, brilliant. Thank.
00:16:24 Ruth Daniels
Thank you very much for speaking to us today.