Assist. Prof. Petya Trendafilova, MPH, RN Faculty of Public Health, Medical University - Sofia

1. Bulgaria Assist. Prof. Petya Trendafilova, MPH, RN Faculty of Public Health, Medical University - Sofia Pepa Vassileva Daniela Gerassimova National Health Policy Directorate,Ministry of Health Bucharest, 9-10 January, 2008

2. Bulgaria

3. Demographic data • Population:7 718 750 - male - 4 269 998 - female - 4 399 271 • Age groups: - under working age: 14.8% - working age: 62.4% - retirement age: 22.8% • Life expectancy:72.55 yrs • Birth-rate:9.2% • Mortality rate:14,6% • Population growth:-5,4%

4. 2001 - 2006 2500 2000 1500 1000 500 0 2001 2002 2003 2004 2005 2006 Child registered cases of violence

5. Child violence in general 2001 75 2002 632 2003 1995 2004 2181 2005 1429 2006 1742 Family Violence (IPV) 47 62.7% 420 66.5 1614 81% 1487 68.2 1103 77.2% 1435 82.4% Street violence - 60 9.5% 80 4% 188 8.6 % 119 8.3% 112 6.4% Violence in educational institutions 9 12% 78 12.4 206 10.3% 311 14,3% 114 8% 110 6.3% Violence on public places 8 10.7 40 6.3% 36 1.8% 45 2.1% 43 3% 69 4% Violence in specialized institutions 11 14.7 34 5.3% 59 2.9% 150 6.8 % 50 3.5% 16 1% Child violence according to the place of perpetration

6. 15 487accepted callssince 1998 2500 1954 2000 1821 1776 1687 1634 1522 1482 1500 1328 1222 1061 1000 500 0 1998 2001 2005 1999 2000 2002 2003 2004 2006 October.07 Hot Telephone Line for IPV: +359 2 981 76 86 Statistics

7. Gender and IPV • Gender role and identity usually include gender inequality in rights and misbalance of power between men and women. • Violence against women and its acceptance in society as a whole is one of the manifestations of gender inequality.

8. Attitude of civil society toward IPV • NCSPO in Bulgaria announced the results from a comparative study of the public opinion towards IPV and according to it 53,7% of people think that the problem is personal and there is no need to be taken any actions to prevent IPV. • Public opinion states that the reasons for IPV could be: financial problems, unemployment, bad upbringing/behavior model, violence in the childhood period, stress, professional problems, non-punishability of domestic violence, violence that can be seen on TV etc.

9. Working with people experienced domestic violence • Police Departments • Social workers • NGOs • (Emergency) medical care personnel • Prosecutors • Courts - under The Family Code The Law on protection against DV The Law on child protection

10. Basic nursing preparation programs in Bulgaria • BSN - 4-year University- 1940 h = 159 credits(not include practice hours) • Practice Clock Hours for BSN; - Clinical practice – 1860 h = 61 credits - Before graduate probationary period – 800 h = 20 credits

11. Significant changes in the nursing curriculum Since 2007 in Bulgaria: In 2010 the first graduate students will become nurses with university bachelor degree. All the other nurses, who already have a college diploma, confer by a law the same status as the new students. Before 2007 the curriculum did not correspond with EC Directives 77/452/EO and 80/154/EO to cover 4600 academic hours = 240 credits.

12. IPV Definition Intimate partner violence (IPV) is essentially a pattern of behavior which is characterised by: • the exercise of control and the misuse of power by one person, usually a man, over another, usually a woman, within the context of an intimate relationship. (Greater London Authority 2001) It could include: • physical, sexual, emotional, and financial abuse, and the imposition of social isolation and is most commonly a combination of them all (Addressing Intimate Partner Violence - Guidelines for Health Professionals in Maternity and Child Health Care).

13. Responsibilities of health professionals • recognize violence • bring up the issue of violence • interview, support and advise the victim • assess the dangerousness of the situation • carry out a careful medical examination and statement • document the impact of violence (injuries, psychological impact, etc.) • talk about the children • report the violence in accordance with child protection laws • refer victims to other help providers • co-ordinate co-operation with other professionals

14. Specific role of health professionals • The role of health professionals is crucial in identification of and assistance tovictims of IPV. • The specific role of health professionals is in identifying victims of violence and in initiating a process of ending this violence. It is therefore important that they co-operatewith other help providers and authorities. • To better meet the needs of IPV victims, medical professionals should receive training not only on the physical consequences of intimate partner violence but also appropriate training and adequate intervention strategies.

15. Need of professional training on violence(IPV) • Ensuring special training on violencefor professionals confronted with violence (IPV): - to give them the means to detect and manage crisis situations and improve the manner in which victims are received, listened to and counselled(concept of gender, all forms of violence, the situation of victims, their coping and support needs, influence of violence on health, appropriate tools for identification of victims of violence, means for securing evidence of violence; methods of consultation, rehabilitation, and/or reintegration into society); - to raise awareness and change attitudes regarding domestic violence (IPV) • Initial vocational training on a compulsory basis: academic course of education required to enter a profession including specific training on violence IPV) offered to all students - nurses and midwives; • Further education: recommend The Associations of Health Professionals to organize further specific in depth education on violence(specifically on methods of prevention and intervention).

16. The challenge to teach IPV Violence against women puts a heavy burden on the health system, it reduces: • women’s working capacities; • the quality of their lives and their lifespan. In highly developed countries like the US partner abuse is the most common reason for injuries in women. Violence does not stop during pregnancy. The time of pregnancy and after delivery can pose an even greater threat to women to be afflicted by intimate partner violence. The real challenge is to develop tools and methods for teaching and mentoring the students about such a sensitive issues as gender based violence is.

17. IPV and practice training of nursing students Recognising violence: • Indicators of physical violence: - Injuries: bruises, wounds, bone fractures, concussions, tooth injuries, scalp injuries, internal injuries, miscarriages, eardrum ruptures, burns; Severity of injury ranges from minimal tissue damage, broken teeth and bones to permanent injury and death; • Indicators of sexual violence: any non consensual sexual activity including sexual taunts and jokes, staring and leering, unwelcome comments, indecent exposure, offensive phone calls, unwanted sexual propositions, forced viewing of or participation in pornography, unwanted touching, coerced sex, rape, incest, performance of forced sexual acts which the woman finds painful or humiliating, forced pregnancies, trafficking in women, and their exploitation by the sex industry; • Indicators of financial violence: poverty, homelessness, debts, unable to provide food and necessities for the family, unpaid bills/inability to pay bills, inadequate food/clothing, unexplained discrepancy between income and living conditions;

18. IPV and practice training of nursing students Psychological trauma caused by violence: • Acute trauma reactions - shock reactions: - Observable behavior/symptoms; - Emotional/cognitive symptoms - Long Term Symptoms (PTSD (Post-Traumatic Stress Disorder) • Consequences of trauma - the impact of trauma makes it very difficult for women to leave a violent partner: - this model of behavior produces emotional bonds and reduces the victim’s ability to make decisions independently

19. Teaching skills of teachers in health care sector • Develop pedagogical skills to teach IPV; • Meet new challenges originated from practical work in health care sector both at national and EU level; • Develop tools and methods for teaching and mentoring the nursing students about gender based violence; • Develop teachers’ involvement in curriculum development in teaching IPV.

20. Teaching IPV in curriculum of nursing students • What has been done? Elective courses – topics: How to interview patients (special attention to IPV victims); Children psychology and pedagogical approaches; Course of psychotherapy for victims of IPV. • What should be done? We have to provide the health professionals with support to recognize violence at an early stage and prevent further violence. • Development needs: to protect children as well as primary prevention of violence occurring in the family; to be given adequate support in case of IPV; special training on IPV, its consequences for women and children and on how to use different tools to prevent IPV. • Problems:Implementing compulsory IPV training courses in the curriculum of nursing education; A lack of special training and teaching tools for teachers on IPV (teachers have not received advanced training on IPV).

21. Relevance of the project proposal for the nursing curriculum • Estimation of the relevance of the project for the curriculum development work. • Violence against women is a phenomenon which has constantly evolved with the passage of time but which remains more present than ever within our society. • The family environment is the scene of the most violence of all types against women and children. • The health professionals, especially nurses should participate in solving problems connected with IPV. • Violence against women is a very sensitive issue to teach as it is sensitive to handle in health care organizations’ everyday practice. Therefore the teachers/trainers, students and health care professionals need special knowledge and skills for their everyday work.

22. Training, supervision and other supportfor health professionals Ways to maintain professionalism and wellbeing: • Knowledge the causes and impacts ofviolence againstwomen and children; • Networking of public authorities and other social partners: violence issues requirecollaboration between different authorities anddevelopment of a network; • Supervision should be self-evident for everyone working in acaring profession, but it is especially important for those working with violence; • Consulting:it is recommended that health professionals can turn to anexperienced person in their own field or to a special expert of another field regardingspecific questions like legal issues; • Continuoustraining: help providers should receive special training on the methodsin violence prevention in addition to their professional education.

23. Expected outcomes • More effective cooperation between the government, medical universities and the civil society; • The implementation of united standards and criteria for health care professionals for work with people experienced IPV; • Awareness-raising activities targeted to a specific audiences; • Increased capacity for adequate response and professional development of health care professionals by implementing the new training programmes teaching IPV issues; • Increased knowledge on violence (IPV) and aggression – reasons, consequences and opportunities for help and support on a national and EU level.

24. THANK YOU !