In the early stages of the COVID-19 pandemic, there was global concern from stakeholders working in the field of violence prevention that, as a result of the public health restrictions in place to limit the spread of the virus, levels of violence would rise and violence support services would be inaccessible [3–6]. Without large-scale population-level surveys, accurately determining changes in incidence or prevalence of violence during the early stages of the pandemic was not feasible [20, 25, 26]. However, administrative data from health and social services, law enforcement, and NGOs were more readily available and provided an initial understanding of levels of service utilisation. The current study used emerging administrative service data from the early stage of the COVID-19 pandemic to examine changes in service utilisation related to VAWC. Overall, findings suggested that there was a median increase in service utilisation related to VAWC of approximately 20% during the early stages of the pandemic. Crucially, however, change in service utilisation differed across sectors with the highest median increase in utilisation for NGOs (48%), a relatively small median increase for law enforcement services (6%), and a small decrease for health and social services (-8%). After categorising each estimate as reflecting an increase or decrease in VAWC service utilisation during the pandemic, there was a significant association between sector and change in service utilisation, with most NGO estimates (95.1%) showing an increase in utilisation, compared to 58.2% of law enforcement estimates, and 42.9% of health and social care estimates. After controlling for the comparison period used to calculate the change in utilisation, multivariate analysis showed health and social service data was 17 times more likely to show a decrease compared to NGO data, whilst law enforcement data was almost 10 times as likely to show a decrease.
Findings in the current study are in line with other global evidence which demonstrates that COVID-19 related disruption of VAWC services is not equally distributed across service types and sectors [15, 17, 27]. A study by UNICEF reported that whilst 66% of countries surveyed reported overall disruptions to VAC-related services, this differed by service type, with only 12% of countries reporting disruptions to child protection helplines compared to 48% reporting disruptions to child welfare authorities [17]. Reports from civil society, women’s rights organizations, and humanitarian services have reported increases in calls and service utilisation related to VAW since the beginning of the COVID-19 pandemic [27]. However, evidence suggests disruptions to law enforcement and health services have been more varied, and whilst increases in utilisation were reported in some countries, many reported decreases in reports of VAW [15]. Thus, evidence suggests that NGO’s, particularly in terms of helpline calls, saw increases in service utilisation during COVID-19, however, use of health services and law enforcement related to VAWC was more varied across countries, and in many cases suggested a decrease in utilisation during the early stages of the pandemic [15, 17, 27].
There are several possible reasons why VAWC service utilisation may have varied across sectors during the pandemic. Without population-level surveys it is difficult to assess any true changes in levels of violence during the pandemic, however, some emerging evidence indicates increased severity of violence and resulting injuries [28]. Thus the fluctuations across and even within sectors in the current study are more likely to represent victims’ ability and willingness to access services during lockdown, rather than actual changes in levels of violence [25]. Existing data prior to the pandemic suggest the majority of cases of violence against women never come to the attention of the authorities. Global self-reported survey data shows that whilst 31% of women aged 15–49 years have experienced physical and/or sexual violence in their lifetime [29], only 40% of women who experience violence report it to someone, and of those who do less than 10% report the incident to the police [30]. Similarly, global evidence suggests self-reported child sexual abuse is more than thirty times higher, and physical abuse more than 75 times higher, than official reports or cases detected by child welfare authorities [31, 32]. A safe environment and a trusted relationship is often a necessary condition for disclosure of violence or abuse [33, 34]. NGOs with established trusted relationships with service users prior to COVID-19 may have thus been better equipped to support clients during the pandemic, than services such as police and health where such relationships are less likely. Further, NGOs in several European countries reported proactively making contact with known survivors and those at risk of violence or abuse to ensure they were safe and to offer support [35].
Those experiencing violence may also have been unwilling to attend health care services during the pandemic for fear of contracting the virus or placing additional burden on the health care system, with emergency departments across Europe showing decreases in attendance related to a range of health concerns during lockdown [36–38]. Furthermore, in the initial stages of lockdown, confusion around stay-at-home orders may have meant victims were unaware they could still seek medical or police assistance. This was addressed in many countries in later months with the implementation of communication campaigns that aimed to increase reporting and highlight stay-at-home orders did not apply to those fleeing abusive homes [35]. Even in cases where survivors presented at health care services, time and space to safely screen for, and identify abuse may have been more difficult. A key response measure in many countries was the reallocation of resources, particularly with respect to health services and law enforcement, to the direct infectious disease response, and thus resource for other activities such as violence prevention and response were reduced, particularly multi-sector coordinated responses [3]. Mandated sources of reporting of child abuse such as teachers, child care providers, and clinicians had fewer opportunities to detect and report signs of abuse during the pandemic due to reduced in-person provision [39–41]. Whilst some countries introduced legislation to help statutory services adapt to remote working and facilitate stay-at-home orders, in some cases this added further barriers to providing victims with support [40, 41]. For example, in the United Kingdom, temporary amendments to children’s social care regulations came into place in April 2020 to no longer require a social worker to perform home visits to a child in care every six weeks, reducing it to ‘as soon as is reasonably practicable’, whilst in France consultation in child welfare services were restricted to emergencies and parent–child meetings in the presence of a social worker were suspended [40, 42]. Thus, services that were traditionally more reliant on in-person provision, such as health services and safeguarding personnel (e.g. teachers), were heavily restricted in their ability to identify victims and provide support. Conversely, many NGOs already had online or telephone service provision in place prior to the pandemic, and thus were better equipped to provide remote support. Furthermore, it is possible that the initial reluctance to attend health services or seek police assistance during the early stages of the pandemic may have led to some of the increase in utilisation of NGO support services.
The findings from the current study, and other early studies on COVID-19 and VAWC, have several important implications and considerations for policymakers in the event of ongoing and future measures related to COVID-19 that limit service provision and access. Crucially, these considerations also have relevance to violence prevention work in future emergencies, natural disasters, and more generally for other times of prolonged presence in the home, for example during Christmas and summer holidays [16]. Firstly, the pandemic has highlighted the crucial role NGOs play in violence prevention and providing support for victims. NGO victim support services must therefore be included on the list of designated essential services that are allowed to continue delivery in the case of any future restrictions [43]. Furthermore, with predictions of a post-COVID-19 global recession [44], and associated cuts to service funding likely, governments should ensure funding is allocated to this sector, to scale up and adapt services where necessary. Lessons on how to engage with survivors and the importance of a trusting relationship and safe space to disclose violence can also be utilised by other sectors. The emerging model of trauma-informed services in many countries is an important step in realising this and providing stakeholders across multiple sectors with the knowledge and skills to initiate disclosures and signpost survivors to appropriate support [45].
Secondly, the pandemic forced many services to quickly adapt to remote working, and to integrate new technologies and innovative services into their offer to ensure provision to their service users was as uninterrupted as possible [41, 46]. The necessity of the situation forced many services to substantially upgrade IT systems in a matter of weeks which otherwise may have taken months or years, in addition to making increased use of technologies such as video conferencing platforms to replace face-to-face meetings [41, 46]. This enabled services to use new and innovative ways of reaching victims and providing them with access to support. For example, in Poland, a fictitious online cosmetic store was set up on Facebook where women experiencing violence could request help by pretending to order products [47]. The French organisation L’Enfant Bleu used a gaming platform to provide a communication route for children and young people experiencing abuse to report it and access support [47]. Such adaptations have the potential to increase service accessibility to victims, particularly where the perpetrator is present in the home and accessing helplines is more difficult, however further research is needed to assess if this approach is effective [48]. Consideration also needs to be given to the potential for a digital divide; many victims from low-and-middle-income countries do not have access to online technology or phone services, with an estimated 445 million ‘unconnected’ adult women globally, thus face-to-face provision remains crucial [49].
Thirdly, whilst the pandemic has brought increased global attention to VAWC, it has also highlighted the difficulties measuring the prevalence, nature, and impact of VAWC, particularly in emergencies such as COVID-19. For example, the current study was limited by having to primarily rely on media-reported changes in levels of service utilisation during the initial stages of the pandemic. Further, even attempts to directly contact country’s key stakeholders in violence prevention to request data was limited, with many unable to provide data, and even where data was provided, problems remained with data quality (e.g. lack of pre-pandemic comparative data). Good data is critical to informing evidence-based policies and tailored programmes to respond to the needs of women and children during and after the pandemic, as well as during any future public health emergencies, conflicts, or natural disasters [50]. For example, in Wales, United Kingdom, a pre-existing violence surveillance system that collates datasets from multiple sectors including police, health, and NGOs, was used to monitor the impact of COVID-19 on levels of violence, and inform targeted responses, prevention activity, and communication and awareness campaigns. [4]. Crucially, data was also used to highlight the extent of violence in private settings and prevent existing violence prevention resources from being reallocated from sectors such as public health and police to the direct infectious disease response [47]. Administrative data systems are often better equipped to measure violence in public spaces than in the home where the victims are more likely to be women and children. Since violence prevention resource allocation is often determined by data evidencing where there is need, creation and consideration of datasets (e.g. NGOs) is crucial. They can provide an indication of levels of more hidden forms of violence both during the current pandemic and in violence prevention efforts more generally. The integration of such datasets in national surveillance systems is recommended best practice by WHO in the Global Action Plan to strengthen the role of the health system, within a multisector response to address VAWC [51]. Such approaches should be used to supplement the information collected in population-based surveys which are the best method for determining the prevalence of VAWC (but still represent an underestimate) and include standardised measures and indicators allowing comparability across countries and regions [20].
Findings in the current study should be interpreted in light of a number of considerations. Comparison periods used to calculate the percentage change in service utilisation varied across the collected estimates. However, we tried to mitigate the potential confounding of this factor by performing a multivariate analysis controlling for comparison period. Whilst data is presented and grouped based on the data source (e.g. police recorded data), comparisons should not be drawn between different countries. Differences between countries in, for example, legal definitions, recording practices, and data quality, mean figures are not directly comparable. Further, data may be related to different time periods or measures (e.g. police data may include incidents, reports, or crimes). As already discussed, much of the estimates were drawn from media sources which may introduce bias as these sources may be more likely to report ‘interesting’ or ‘shocking’ statistics and we had no way to check the accuracy of the reports. Whilst the study focused on VAWC service utilisation across the whole WHO European Region our searches were conducted in English and Russian and thus may have missed media reports in other languages. Further, whilst the survey requesting data from key stakeholders was sent to representatives across the whole WHO European Region, the quality of responses varied greatly.
