Difference and opportunity - health visiting interventions with abused women from collectivist and honour-based communities

Dr Catherine Smyth sets out the issues and challenges faced by health visitors when the caseload includes women from these hard-to-reach groups 

Difference and opportunity - health visiting interventions with abused women from collectivist and honour-based communities

Dr Catherine Smyth Specialist Professional Advisor, Care Quality Commission

Key points

  • Hard-to-reach groups are a key challenge 
  • They include women from collectivist and honour-based communities
  • These communities can be tight-lipped about domestic abuse
  • Western-centric health visiting often fails to persuade these women to confide
  • Health visiting focus may need to shift from individuals to communities
  • Care planning should have a nuanced understanding of these women’s circumstances and experiences
  • Assessment tools need to be dynamic, interventions need to be responsive
  • Health visitors need to work in ways that are culturally sensitive yet keep women safe.


Research suggests that the nature of the violence suffered by many Pakistani women often differs from that seen in other ethnic groups. There is also evidence to indicate that abused women living within collectivist and honour-based communities in Britain can pay a high price for their involvement with healthcare professionals.

This poses significant problems for health visitors, as the western model of healthcare may be at odds with the reality of everyday life for many Pakistani women. Drawing on findings from a recent Government review into integration and opportunity in isolated and deprived communities, and a study of health visitors working among a Pakistani population in the north of Britain, this paper sets out the issues and challenges facing many practitioners.

Implications for practice are that mainstream domestic abuse interventions should be employed with sensitivity to the different cultural contexts in which many Pakistani mothers live, and attempts should be made to develop appropriate interventions that derive from those contexts.

The recommendation is that healthcare professionals (and other agencies) should take a broader view of domestic violence so that ‘difference’ is recognised. This would enable health visiting interventions to be flexible and responsive to differing needs, including a consideration of using more community-based interventions among certain population groups.

Key words: Domestic violence, Pakistani, honour, collectivist, health visiting


In July 2015, at the request of the then Prime Minister and Home Secretary, Dame Louise Casey was asked to undertake a review into integration and opportunity in some of the most isolated and deprived communities in Britain. While aiming to take a broad look at social and economic exclusion, and at equality and division across a range of communities and social groups, her report had a significant focus on people of Pakistani and Bangladeshi ethnicity as these communities are said to suffer significant disadvantage across a range of measures relative to other population groups (Casey, 2016).

Published in December 2016, the report was met with mixed reviews, particularly among some Muslim groups who argued that it confuses race, religion and immigration, and focuses too heavily on Muslim communities (Taylor, 2016). Perhaps in anticipation of such a response, in the foreword of the review, Dame Casey acknowledges that the content of the paper will be hard to read for some people living within these communities (Casey, 2016). She goes on to highlight, however, what she believes might be the consequences of shying away from talking about ‘difficult and uncomfortable problems’. She makes specific reference to women and children being the targets of ‘regressive practices’ in certain communities, and suggests leaders and institutions are often not doing enough to make a stand against these practices and protect those who are vulnerable.

The aim of this paper is to use Dame Casey’s findings to set the context of a recent study of health visitors working among a Pakistani community in the north of Britain (Smyth, 2016). The aim of the research is to improve understanding of issues that health visitors face when working with Pakistani mothers who are living with domestic abuse. The study also, however, provides a glimpse into the wider challenges health visitors can encounter when working more generally among collectivist and honour-based communities. It raises questions about some of the philosophical assumptions usually associated with western models of healthcare.

Collectivist and honour-based communities in Britain

Collectivism is a cultural pattern and, sometimes, a political and economic configuration, which prevails in the Middle East and in certain countries around the Mediterranean Sea, as well as in Africa, Asia, South America, the Pacific, and many Eastern European countries (Haj-Yahia & Sadan, 2008; Triandis, 2001). Examples of collectivist culture include those of Chinese, Indian and Pakistani heritage. A further intrinsic part of the identity of many population groups of South Asian origin is the characteristic of honour (Metlo, 2012).

While acknowledging that communities and populace rarely consist of one homogeneous group, the literature suggests that, in diaspora, many practices associated with collectivist and honour-based cultures persist among immigrant South Asian groups in the UK (Azam, 2006; Harriss & Shaw, 2009). The term ‘South Asian’ in this paper refers to someone whose ancestral roots lie in countries of the Indian subcontinent, including those who are British born.

Members of collectivist communities are usually characterised by a sense of emotional, moral, economic, social, and political commitment to their collective. That commitment is reflected in a strong desire by members to meet the needs and expectations of their collective. There is often a wish for members to be in harmony with their collective as well as to maintain harmony. Members will often sacrifice personal needs, aspirations, goals and expectations for the benefit of their collective (Haj-Yahia, 2011).

Honour in some collectivist and honour-based cultures can be associated with dignity and integrity; however, honour is generally seen as residing in the bodies of women. Frameworks of honour - and its corollary, shame - therefore often operate within the family or community to control, direct and regulate women’s sexuality and freedom of movement by male members of the family (Coomaraswamy, 2005).

An ‘honour’ crime is one of a range of violent or abusive acts, committed in the name of honour, to justify violence against women in the name of religion and culture. It is essentially about defending family honour or the honour of the community (Siddiqui, 2005). In this context, the word ‘honour’ carries connotations that may encourage perpetrators to view their actions as morally defensible, so is enclosed in quote marks to stress the problems inherent in using this term.

In collectivist societies, there is a tendency to relate to violence against women more as a personal and family issue than as a social and criminal problem, and members of the collective will often strongly prefer that domestic violence is kept within the family (Haj-Yahia & Sadan, 2008). ‘Honour’ crimes perpetrated against individuals by family members can be seen as being justified in order to conserve family reputation or status within the community, and can be the reason why some women are unable to leave abusive situations (Siddiqui, 2005). Abused women in many collectivist societies therefore tend to conceal their suffering and ask for help only in the most severe and ongoing cases of violence, and after they have made every attempt to deal with the situation on their own (Haj-Yahia & Sadan, 2008; Lee & Hadeed, 2009). Requests for assistance from healthcare practitioners and the practitioners’ desire to intervene can be seen as an attempt to undermine the harmony of the family and arouse intense anger towards the woman. There may often be tremendous pressure exerted on the women by the family to sever connections with the practitioner (Haj-Yahia, 2011). Health visitors working with abused women from collectivist and honour-based populations potentially face complex issues, particularly as intervention models tend to be based on ideologies intended for application in western individualist societies.

Research into domestic violence and South Asian communities in Britain

To date, much of the contemporary British research and subsequent influence on health visiting interventions with abused women has been western-centric in its focus and predominantly relates to violence occurring between intimate partners (see Dennis, 2014; Peckover, 2003a, 2003b). This methodology can therefore frequently overlook the wider challenges that health visitors may encounter when working among collectivist and honour-based communities in Britain.

Research by Smyth (2016) was based on first-hand accounts from health visitors working in a Pakistani community in the north of Britain. The findings suggested that, with regards to this population group, domestic abuse is often a complex aspect of health visiting practice, compounded by deep-rooted cultural and social practices within many Pakistani families. In addition to intimate partners, the study finds that in many cases the perpetrators of abuse are members of the extended family, which frequently includes other women living in the same household. Fear of shame and a deep desire to uphold family honour appear to be significant issues for abused Pakistani women, and non-disclosure is the key challenge faced by health visitors in the study.

The study finds that it is this hidden nature of abuse within such households and the apparent silencing of women that is often the key barrier to women seeking or receiving help, rather than a lack of specialist support available. The main approach taken by practitioners in this situation appears to be predominantly one of harm minimisation - in other words, health visitors employ a variety of measures designed to reduce the harmful consequences of the situation because they are frequently unable to prevent those behaviours that are causing harm to the woman.

The concept of ‘presence’ is described in the study to depict a range of actions often carried out by the health visitors linked to ‘seeing’ or ‘being with’ women, and includes carrying out repeated enquiry into abuse and ‘watchful waiting’. The term ‘covert actions’ is used to encompass a range of seemingly hidden or concealed activities undertaken by practitioners in an endeavour to maintain presence in the home. These can consist of increased surveillance and fabricating reasons to visit families.

The Casey Review

This review reported that in 21st century Britain, people of Pakistani and Bangladeshi ethnicity tend to live in more residentially segregated communities and in higher concentrations than other ethnic minority groups. Moreover, these concentrations at electoral ward level are growing in many areas. The Casey Review also describes how women in some of these communities are facing a double onslaught in which gender inequality is combined with religious, cultural and social barriers. Together, these factors prevent them from accessing even their basic rights as British residents.

Violence against women remains prevalent in domestic abuse, but also in other criminal practices, such as female genital mutilation, forced marriage and honour-based crime. The consequence for health visiting practice is therefore that many practitioners will be increasingly working in geographical areas where caseloads hold high and concentrated numbers of families of South Asian origin and where trying to support abused women and keep them and their children safe remains a complex and under-researched area of practice.

Implications for practice

A fundamental and considerable challenge for health visiting practice is how to engage with hard-to-reach groups and work towards addressing inequalities in health. A fairer distribution of healthcare, however, means providing services in ways relevant to the individuals and the populations served, and women from some Pakistani communities in Britain appear to live very isolated lives. There is a necessity for health visiting practice to look again at how the specific needs of those from honour-based and collectivist populations living in Britain are assessed and met. With reference to domestic abuse, Smyth (2016) has provided further understanding of how the life circumstances of individuals living in collectivist groups are largely influenced by the characteristics of the collective.

Points for consideration and recommendations for future practice include a reevaluation of how some of the philosophical assumptions associated with Western models of healthcare - such as health visiting - occasionally sit uneasily alongside the ideologies of some minority ethnic groups living in Britain – for example, Pakistani families. A paradigm shift of focus from working with the individual to the collective should therefore be considered by health visitors when working with such population groups. Services may want to ask themselves: who is the client - the individual or the collective? In future, practitioners should begin to deliberate on how engagement with significant figures from the collective could further contribute towards the protection of the woman and her children, and perhaps serve as a powerful source of instrumental and emotional support for them.

This proposed change in focus is also consistent with the philosophy underpinning the community level of service delivery described within the Health Visitor Implementation Plan (Department of Health, 2011), which promotes community capacity building to enable families and communities to build on their strengths to improve health outcomes. Casey (2016) reports: ‘Too many public institutions, national and local, state and non-state, have gone so far to accommodate diversity and freedom of expression that they have ignored or even condoned regressive, divisive and harmful cultural and religious practices, for fear of being branded racist or Islamophobic,’ (p.16). Health visitors need to remember that addressing inequalities does not mean treating everybody the same or providing a unidimensional approach to practice. Comprehensive assessment and care planning at both an individual and community level should be able to provide a nuanced and sophisticated understanding of the lived experience of all women living with abuse. Assessment tools need to be dynamic enough to capture the silent escalation of risk that can be evident in families where abuse is hidden and denied. Service providers and commissioners should take a broader view of domestic violence that recognises ‘difference’ and therefore enables health visiting interventions to be flexible and responsive to differing needs.


Despite the growing diversity of our nation and the general sense that most people from different backgrounds integrate successfully, it is evident that there are many areas in Britain where minority ethnic and faith communities are increasing in both concentration and segregation. Social isolation and notions of honour and shame in some communities, including fear of censure from wider family, means that for many women from collectivist and honour-based cultures, domestic violence and honour crimes are prevalent, but rarely disclosed. Health visitors working among those communities therefore need to be equipped to practise in ways that are culturally sensitive yet effective in keeping women safe.

In her 2016 review into integration and opportunity in Britain, Dame Louise Casey proposes that leaders are required at all levels – in Government, in public sector and faith institutions, and in communities – to ‘stand up and be more robust’ against perpetrators of violence (p.16). It is suggested here, and is commensurate with key features of the 2011 Health Visiting Implementation Plan, that health visitors are key public health professionals, ideally placed to provide some of that community leadership. Furthermore, those commissioning and providing health services within areas of mixed ethnicity should reevaluate some of the philosophical assumptions associated with Western models of healthcare. Consideration should be given to the provision of more community based interventions when local intelligence suggests certain population groups are of a collectivist and/or honour-based culture.


This paper is entirely my own work and is not supported by any outside organisation. No financial relationships relating to the submitted work and any third party are in place. There are no conflicts of interest.


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