Missed opportunities in health sector responses to violence against women and girls: a comparative mixed-methods study in Albania and Brazil.

BACKGROUND

Violence against women and girls (VAWG) is a global public health crisis, affecting one in three women worldwide. Survivors of VAWG access health services more frequently due to the direct and indirect consequences of violence. Despite the health system's potential lifesaving role, these visits often result in missed opportunities.

METHODS

The Missed Opportunities to Respond to Violence Against Women and Girls in the Health Sector (MISSOP) study investigated the nature, scale and determinants of missed opportunities in responding to VAWG within primary care and emergency departments in Tirana, Albania and Belo Horizonte, Brazil. Using a triangulated mixed-methods design with an intersectional systems thinking lens, we built a retrospective cohort of women affected by VAWG, analysed their health service use and conducted focused ethnography through observations and interviews with health professionals and survivors to understand why missed opportunities occur.

RESULTS

Missed opportunities emerged as a discontinuum of care. In both settings, failures occurred across the continuum, ranging from access, detection, care and referral to statistics. In each municipality, 42% of women had not accessed any public healthcare facility in the 5 years investigated. Among the 58% who accessed public healthcare services, missed detection rates ranged from 68% in Belo Horizonte to 100% in Tirana's primary care system.These gaps were shaped by a complex interplay of factors, the biomedical orientation of health systems and by intersecting systems of discrimination, such as racism, sexism and classism, that shaped provider attitudes and institutional responses. Although protocols for responding to VAWG existed in both settings, they were poorly implemented or unknown to providers.

CONCLUSION

Despite contextual differences, both health systems showed a similar pattern of systemic neglect. By conceptualising missed opportunities as a reinforcing cycle, our study introduces a novel framework to understand and address institutional failures. This approach highlights the complexity of VAWG as a health system challenge and identifies leverage points for structural and cultural reform.