Introduction

The Solomon Islands is a developing South Pacific country consisting of 992 islands with a population of 572,000.[¹] The country has nine hospitals and the National Referral Hospital (NRH), situated in the capital Honiara, is the largest.[²] We are a group of six medical students from the UK who undertook a medical elective at the NRH in May 2015. Overseen by the Ministry of Health, the NRH is the only tertiary center in the country and is run by 73% of the country's doctors.[³] The hospitals provide free health care but lack funding, resources, and staff.

Gender inequality remains a major issue in the Solomon Islands as documented in the World Health Organization report in 2011.[⁴] Furthermore, the country has one of the highest rates of family and sexual violence (FSV) in the world, with 64% of women aged 15–49 reporting physical or sexual abuse.[⁵]

A 2009 study revealing high rates of FSV in the Solomon Islands concluded that a multi-factorial approach to tackling attitudes toward gender-based violence was necessary, involving politics, public health, communities, and healthcare policies.[⁵] Nevertheless, in 2011, the World Health Organization reported that 73% of men and women still believed gender-based violence was acceptable.[⁴]

The article reflects our experience of FSV in the Solomon Islands in the context of a medical elective and our thoughts on the current strategies in place to help victims of domestic abuse, and compare the differences in management of FSV between the UK and Solomon Islands and explore possible reasons for such differences and finally, determine if further action should be taken to tackle FSV in the Solomon Islands.

Our Personal Experience of Family and Sexual Violence in the Solomon Islands

During our elective, our focus on FSV stemmed from the 2014 case series detailing all reported cases of FSV at NRH between 1994 and 2011, which showed a staggeringly high rate of FSV cases at this hospital, particularly with regard to violence against women.[⁶] Each student worked in different departments of the hospital, and it became evident that FSV is still a major cause of concern, especially in the Emergency Department (ED) and Obstetrics and Gynecology Department.

While on the wards, we came across multiple cases of possible FSV. Many patients presented to ED with patterns of injury and psychological distress consistent with FSV and healthcare professionals struggled in the management of these patients. In particular, healthcare workers often did not explore the history of a presenting complaint beyond the story given. The overcrowding in ED put staff under pressure to see, treat, and discharge patients as soon as possible, allowing limited time for a thorough history. In particular, social history was largely forgotten, a component which is vital in cases of FSV.

Unusual injury patterns which would raise concerns in the UK were not investigated in details in Solomon Island as healthcare workers often accepted the parental account of the history without further investigation into how the injuries were sustained.

We could not help but feel concerned that a potential FSVs being discharged after medical management without any investigation or protection might be not proper.

In addition to our clinical experience of FSV, we interacted with other international volunteers and the Royal Assist Mission to the Solomon Islands (RAMSI) and conducted informal discussions about current and future initiatives to tackle FSV. RAMSI is an Australian-led policing mission who work alongside the Royal Solomon Islands Police Force.[⁷] Some of the healthcare volunteers and policemen were specifically placed in the Solomon Islands to focus on raising awareness, changing perceptions and implementing schemes to tackle FSV.

What is Already Being Done to Tackle Domestic Violence in the Solomon Islands?

In the healthcare setting

A FSV reporting folder has recently been implemented in the ED at the NRH. This folder includes structured forms for staff to complete in order to document cases of suspected FSV for further investigation. However, we noticed that during our placement, this was rarely done, and when cases had been filed, little had been done to refer them to further services. Many health care professionals felt that they would only report “obvious” cases and were apprehensive about investigating a patient who might be a potential victim of domestic violence.

While speaking to an international volunteer with a special interest in domestic violence, we learned that there is a hospital manual in the end stage of production, which aims to educate healthcare workers on recognizing and managing a patient who has experienced FSV. The manual was requested by healthcare professionals in the Solomon Islands and will be taught as a modular course, covering aspects such as performing relevant medical examinations, how to provide psychological support and understanding the current legislation. This course aims to be implemented in 2016. A final version of the manual is yet to be produced, largely due to lack of funding.

Criminal justice system

We spoke informally to multiple RAMSI policemen, several of whom were working specifically on tackling FSV in the Solomon Islands. They discussed with us that tackling FSV was one of their four major reasons for taking residency in the Solomon Islands[⁷] and spoke of the specific initiatives that they had introduced to try and tackle FSV in the Solomon Islands. Following our discussions, we looked at specific areas of their website to gain further understanding of such initiatives.

For example, RAMSI are training Solomon Island police officers to change their own perception of FSV and providing them with skills to collate data, investigate FSV and keep victims of abuse safe. They also accompany local police officers into communities to help raise awareness and change perceptions on FSV. Similarly, in 2009, RAMSI helped launch the “Naf Nao” campaign which aimed to encourage Solomon Islanders to speak out about domestic violence, which is traditionally not spoken about outside of the family. Several billboards, which have been funded by RAMSI, have been erected on the streets of Honiara, to further spread these messages.[⁸] Furthermore, a series of guidelines have been developed by RAMSI to aid the immediate management of FSV as well as public information leaflets to increase awareness.[⁹]

Finally, RAMSI helped to implement the Family Protection Act 2014.[¹⁰] This legislation means that domestic violence is now considered a crime in the Solomon Islands. It is now easier for the police to intervene on matters of family violence.[¹¹] In addition, Section 46 of the Act serves to inform healthcare professionals of their new legal obligation to examine and investigate domestic violence in a clinical setting. Medical professionals are also required to signpost victims to support services. Section 46 continues to advise that in cases of child abuse there is a legal obligation to report to social services or the police.[¹²]

Discussion

Although the schemes aimed to tackle FSV have been introduced into the Solomon Islands, from our experience, it seems that they are not commonly implemented in clinical practice. Patients are not routinely flagged up as potential victims of FSV, with further investigations and relevant referrals often failing to occur. Furthermore, the police force and healthcare professionals do not currently work together in suspected cases of FSV, and healthcare professional seemed unsure about other support services that may exist.

In the UK, various bodies and organizations provide guidance on the management of domestic violence and child abuse, such as the General Medical Council (GMC) and the National Institute of Clinical Excellence (NICE). These GMC guidelines state that doctors should work in partnership and have effective communication with other statutory agencies and child protection agencies, to ensure that all aspects of the case are accounted for.[¹³] This supports the notion that collaboration across the services in the Solomon Islands could help protect vulnerable women and children from further FSV.

Reflecting on positive aspects of FSV management in the UK and identifying areas that could potentially be implemented in the Solomon Islands are important. However, the barriers to change described throughout this article, such as limited social service resources, must be taken into account when doing so. General themes and approaches that are more readily possible include vigilance, low threshold of suspicion, thorough history taking and documentation.[¹³¹⁴] However, two aspects of the guidance described by the NICE that would be more challenging to implement would require the implementation of formal support and referral systems adopted widely across the health system.[¹⁴]

It is important to note that FSV initiatives have only recently been introduced into the Solomon Islands and that they are largely based on Western models. These Western models have a large emphasis on many of the described aspects described above including the health care professional taking thorough histories from patients and encouraging them to speak out about their experiences of domestic violence. Referring victims of FSV to other relevant support services, and following them up is another key area that is emphasized in several western protocols for domestic violence.[¹³¹⁴] In the Solomon Islands, FSV traditionally is a topic that would not be addressed outside of the family setting. Therefore, implementing western guidelines, in which both the patient and health care professional are encouraged to discuss FSV together, may take time to implement. Furthermore, it seemed that health care professionals did not know which support services were available to victims of FSV, and how they could refer them. Therefore, support services may need to become more firmly established, and health care professionals may need to be educated about the further services that are available to victims of FSV. For these reasons, it may take several years to see the impact of current strategies on reducing domestic violence in the Solomon Islands. Similarly, the domestic violence hospital manual has not yet been published for use at the NRH. The training which this manual provides has the potential to enable healthcare workers to greatly improve holistic management of FSV patients.

Conclusion

Domestic violence is a major public healthcare concern in the Solomon Islands. From our experiences and interactions with people working in this area, it is evident that numerous interventions are being developed and implemented. However, these interventions are still in their infancy and have largely stemmed from Western protocols. Therefore, for these models to be effective, time and commitment is needed to change the cultural perception of domestic violence in the Solomon Islands.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.