Mapping and exploring health systems' response to intimate partner violence in Spain

What a critical public health perspective can add to the analysis of healthcare responses to gender-based violence that focus on asking

In this comment I analyze the effects of approaching gender-based violence as a public health problem, that the health system should address through 'daring to ask'. I acknowledge the potential of the 'daring to ask' strategy, but I also argue that asking has effects, and that we should be aware of them.

A Systematic Review of Culturally Competent Family Violence Responses to Women in Primary Care

Existing culturally competent models of care and guidelines are directing the responses of healthcare providers to culturally diverse populations. However, there is a lack of research into how or if these models and guidelines can be translated into the primary care context of family violence. This systematic review aimed to synthesise published evidence to explore the components of culturally competent primary care response for women experiencing family violence. We define family violence as any form of abuse perpetrated against a woman either by her intimate partner or the partner's family member. We included English language peer-reviewed articles and grey literature items that explored interactions between culturally diverse women experiencing family violence and their primary care clinicians. We refer women of migrant and refugee backgrounds, Indigenous women and women of ethnic minorities collectively as culturally diverse women. We searched eight electronic databases and websites of Australia-based relevant organisations. Following a critical interpretive synthesis of 28 eligible peer-reviewed articles and 16 grey literature items, we generated 11 components of culturally competent family violence related primary care. In the discussion section, we interpreted our findings using an ecological framework to develop a model of care that provides insights into how components at the primary care practice level should coordinate with components at the primary care provider level to enable efficient support to these women experiencing family violence. The review findings are applicable beyond the family violence primary care context.

Disclosing Gender-Based Violence: A Qualitative Analysis of Professionals' and Women's Perspectives through a Discursive Approach

Supporting women to disclose gender-based violence (GBV) is a central feature of how healthcare and other welfare services address this problem. In this paper we take a discursive approach to analyse the process of disclosing GBV from the perspectives of young women who have been subjected to GBV and professionals working in the welfare system. Through a reflective thematic analysis of 13 interviews with young women who have been subjected to GBV and 17 with professionals working in different sectors of the welfare system, we developed four themes about how disclosure is perceived: (i) as a conversation between acquaintances; (ii) as 'no solution'; (iii) as a possible prerequisite for action; and (iv) as difficult because GBV is normalised. Even if disclosure is not the solution per se, it makes it possible to respond institutionally to GBV on an individual basis through the figure of the expert professional who is alert to signs, knows how to support disclosure, and has the power to legitimate women's claims of GBV. We acknowledge the possibilities that supporting disclosure brings for women subjected to GBV, but at the same time, problematise that it can re-centre expertise in the professional and place the responsibility on women.

Psychosocial Separation and Women's Disengagement From Prosecutions Against Abusive Intimate Partners in Spain

In order to end and "liberate" themselves from an abusive relationship, female survivors of intimate partner violence (IPV) usually face a complex process. Although women may decide to seek help through the criminal justice system, some refuse to participate in legal proceedings against their abusers. While many studies have focused on exploring variables explaining disengagement from legal proceedings, the aim of this article is to study the impact of the process of liberation from an abusive relationship on the likelihood of disengagement (LoD) from legal proceedings. Liberation was measured through the psychosocial separation overall score and the LoD was predicted by a logistic regression model developed in a previous study in Spain. A sample of 80 women involved in legal proceedings for IPV against their ex-partners in Andalusia (Spain) participated in this study. Exploratory analyses were conducted using ANOVA and Chi-square; multiple linear regression analyses were used to study the relationship between psychosocial separation and LoD. Results showed that victims who had higher psychosocial separation from their abusers were less likely to disengage from legal proceedings against the abuser. We discuss the results in terms of practical implications like detection of women's need for specific psychological support to ease a comprehensive recovery. Training programs for legal professionals and judges in the judicial arena should use the results of this study to increase professionals' understanding of IPV and survivors' decision-making processes. This would lead to a decrease in survivors' secondary victimization, as well as decrease the frustration of legal professionals when victims disengage from legal proceedings.

A qualitative content analysis of nurses' perceptions about readiness to manage intimate partner violence

AIMS

To explore the perceptions of nurses on the factors that influence their readiness to manage intimate partner violence (IPV) in Spain.

DESIGN

Qualitative content analysis based on data from six different regions in Spain (Murcia, Region of Valencia, Castile and Leon, Cantabria, Catalonia, Aragon) collected between 2014 and 2016.

METHODS

37 personal interviews were carried out with nurses from 27 primary health care (PHC) centres and 10 hospitals. We followed the consolidated criteria for reporting qualitative research guidelines. Qualitative content analysis was supported by Atlas.ti and OpenCode.

RESULTS

The results are organised into four categories corresponding to (1) acknowledging IPV as a health issue. An ongoing process; (2) the Spanish healthcare system and PHC service: a favourable space to address IPV although with some limitations; (3) nurses as a key figure for IPV in coordinated care and (4) factors involved in nurses' autonomy in their response to IPV, with their respective subcategories.

CONCLUSION

In practice, nurses perceive responding to IPV as a personal choice, despite the institutional mandate to address IPV as a health issue. There is a need to increase continuous training and ensure IPV is included in the curriculum in university nursing undergraduate degrees, by disseminating the existing IPV protocols. Furthermore, coordination between healthcare professionals needs to be improved in terms of all levels of care and with other institutions.

Exploring sustainable primary care responses to intimate partner violence in New Zealand: Qualitative use of complexity theory

OBJECTIVE

To explore what affects sustainable responses to intimate partner violence within New Zealand primary care settings using complexity theory.

DESIGN

Primary care professional interviews on intimate partner violence as a health issue are analysed using a complexity theory-led qualitative research methodology grounded in poststructuralism.

SETTING

Four general practices in one region of the North Island of New Zealand, two serving a general patient population and two adopting an indigenous approach.

PARTICIPANTS

Seventeen primary care professionals and management from the four recruited general practices.

RESULTS

The complex adaptive system approach the 'Triple R Pathway', calls attention to system interactions influencing intimate partner violence responsiveness across health system levels. Four exemplars demonstrate the use of the Triple R Pathway. Two key system areas challenge the emergence of primary care responsiveness: (1) Non-recognition of intimate partner violence as a key determinant of ill-health. (2) Uncertainty and doubt.

CONCLUSIONS

The relationship between intimate partner violence and ill-health is not well recognised, or understood in New Zealand, at both policy and practice levels. Inadequate recognition of socioecological determinants of intimate partner violence leads to a simple health system response which constrains primary care professional responsiveness. Constant intervention in system interactions is needed to promote the emergence of sustainable responses to intimate partner violence.

Analysing training in gender-based violence for undergraduate nursing students in Spain: A mixed-methods study

BACKGROUND

Health-care professionals, and nurses especially among them, play an essential role in the health sector's response to gender-based violence. To be able to successfully address this major public health issue they need specific training in the topic.

OBJECTIVE

To analyse training on gender-based violence that nursing students receive at universities in Spain.

DESIGN

Mixed-methods approach.

SETTING

Spain.

METHODS

Systematic review of public documents followed by in-depth interviews with university lecturers.

RESULTS

Eighty per cent (92/115) of nursing training programmes included content regarding gender-based violence. There was great variability in the topics included in the training. Health consequences due to gender-based violence exposure and the role of the health sector in addressing these health consequences were the most frequently included topics. Ethical issues and legislation were the least frequent ones, as these were only dealt with in one and 18 training programmes, respectively. In the qualitative analysis of the interviews, two categories were identified: 'Supportive legislation and supportive lecturers are essential for integrating gender-based violence training' and 'Approach to gender-based violence shapes the contents and the subject in which it is incorporated'. The first category refers to the main drivers for training integration, while the second category refers to how lecturers' perceptions influenced the way in which training was implemented.

CONCLUSIONS

As many as 80% of the nursing education programmes included specific training in gender-based violence, although with great variability in the contents among the universities. For this study's participants, enacted legislation, and lecturers interested in the topic and in decision-making positions were key drivers for this extensive implementation. The variability observed across universities might be explained by lecturers' different approaches to gender-based violence and the nursing profession.

Nursing students' discourses on gender-based violence and their training for a comprehensive healthcare response: A qualitative study

BACKGROUND

Gender-based violence is a worldwide major public health issue with detrimental effects on the health of women. Nurses can play an essential role in its identification, management and prevention. Specific training is essential to be able to successfully address gender-based violence and accordingly, has been incorporated into many university's training programmes for nurses and other health care professionals. Research aimed at exploring attitudes and perceptions of gender-based violence in undergraduate student nurses following these new training programmes is scarce.

OBJECTIVE

The aim of this qualitative study was to explore third- and fourth-year nursing students' perceptions and attitudes toward gender-based violence.

DESIGN

A focus groups based qualitative study.

SETTING

A public University in Spain.

PARTICIPANTS

Purposive sample of 42 nursing students who joined 7 focus groups.

METHODS

Focus groups discussions following a semi-structured interview guide. Discussions were transcribed and analysed following critical discourse analysis to identify interpretative repertoires.

RESULTS

From the analysis, three interpretative repertoires emerged. The first, 'Gender-based violence is something serious', reflected participants' acknowledgment of the social relevance of this type of violence. The second interpretative repertoire, 'Men are defenceless!', related to the perception that national legislation on gender-based violence was discriminatory to men and the perception of a lack of social sensitisation toward intimate partner violence against men. The last one, 'Trained to address gender-based violence but still unprepared' encompassed participants' confidence in their ability to identify gender-based violence but uncertainty as to how to respond to gender-based violence exposed women in terms of professional practice.

CONCLUSIONS

Participants perceived that training has increased their knowledge and self-confidence in identifying cases. However, training should strongly challenge widespread myths about gender-based violence that could negatively affect their performance as nurses.

Health Providers' Narratives on Intimate Partner Violence Against Roma Women in Spain

This qualitative study identifies health professionals' dominant, adaptive, and liberating narratives regarding inter-ethnic relations when talking about intimate partner violence (IPV) and the health system responses to the way it affects Roma women. Dominant narratives are oppressive internalized stories that shape social perceptions of members of both dominant and minority groups, adaptive narratives refer to those that acknowledge asymmetry and inequality, and liberating narratives directly challenge oppression with resistant views of stereotypes and negative interpretations. A total of 25 in-depth interviews were carried out with healthcare professionals in Spain in 2015. A discourse analysis of the interview transcriptions was conducted, showing the way in which different narratives about Roma people and IPV are combined among health providers. Dominant narratives were more salient: they were used by health providers to reflect prejudicial social perceptions in Spain that depict the Roma as a marginalized and traditional group, to construct Roma women in negative and prejudicial terms as patients, and to explain the existence of the cultural normalization of IPV among Roma women. Adaptive and liberating narratives showed a prevailing ideology in terms of the tendency to socially discriminate against Roma people. Using liberating narratives to train and raise awareness among health professionals about IPV among Roma women could facilitate a positive change in their treatment of Roma women who could be affected by IPV, helping to ameliorate the maintenance of existing prejudices.

Health-Sector Responses to Intimate Partner Violence: Fitting the Response Into the Biomedical Health System or Adapting the System to Meet the Response?

This study aims to analyze how middle-level health systems' managers understand the integration of a health care response to intimate partner violence (IPV) within the Spanish health system. Data were obtained through 26 individual interviews with professionals in charge of coordinating the health care response to IPV within the 17 regional health systems in Spain. The transcripts were analyzed following grounded theory in accordance with the constructivist approach described by Charmaz. Three categories emerged, showing the efforts and challenges to integrate a health care response to IPV within the Spanish health system: "IPV is a complex issue that generates activism and/or resistance," "The mandate to integrate a health sector response to IPV: a priority not always prioritized," and "The Spanish health system: respectful with professionals' autonomy and firmly biomedical." The core category, "Developing diverse responses to IPV integration," crosscut the three categories and encompassed the range of different responses that emerge when a strong mandate to integrate a health care response to IPV is enacted. Such responses ranged from refraining to deal with the issue to offering a women-centered response. Attempting to integrate a response to nonbiomedical health problems as IPV into health systems that remain strongly biomedicalized is challenging and strongly dependent both on the motivation of professionals and on organizational factors. Implementing and sustaining changes in the structure and culture of the health care system are needed if a health care response to IPV that fulfills the World Health Organization guidelines is to be ensured.

Violence committed by intimate partners of physicians, nurses and nursing assistants

AIM

To estimate the prevalence of intimate partner abuse in physicians, nurses and nursing assistants and risk factors in the Spanish Health Service.

BACKGROUND

In Spain, the national public health service is the most likely point of primary care access for victims of intimate partner violence. However, health professionals are also victims of violence by their intimate partner. Little research has been undertaken exploring the prevalence and risk factors of this abuse in health professionals.

METHODS

A cross-sectional multicenter study in professionals of both sexes who were working in the Spanish Public Health Service was performed. The health professionals completed an online survey of intimate violence abuse: for women, the screening of abuse against women by an intimate partner, and for men, the domestic violence screening tool in a family setting. A descriptive and comparative analysis was performed.

RESULTS

The sample consisted of 1071 professionals: 49.9% were physicians, 46.9% were nurses and 3.3% were nursing assistants. Of the participants, 26.6% had experienced some form of abuse, and 73.3% of the abused professionals had not spoken of their experience of abuse with anyone else.

CONCLUSION

Men experienced a lower incidence of intimate partner violence than women. In fact, 34% of the female participants were in an abusive relationship, which is a higher percentage than that observed in studies of the general Spanish female population (11.7%). It appears that being female and a nurse are risk factors for abuse.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

These data suggest the urgent implementation of action plans for the provision of support for the victims and for interventions aimed at reducing the problem. Better training and awareness-raising programmes that improve the detection of intimate partner violence and the care of its victims are also necessary.

Priorities and strategies for improving Roma women's access to primary health care services in cases on intimate partner violence: a concept mapping study

BACKGROUND

With an explicit focus on Roma women in Spain (Kale/Spanish Gypsies), this study aims to integrate key informants' opinions about the main actions needed to improve primary health care services' and professionals' responses to Roma women in an Intimate Partner Violence (IPV) situation.

METHODS

Concept mapping study. A total of 50 (brainstorming phase), 36 (sorting and rating phase) and 16 (interpretation phase) participants from Roma civil society groups, primary health care professionals and other related stakeholders (social services, academic experts and other IPV NGOs representatives) from different cities in Spain were involved in the different study phases.

RESULTS

Among the 55 action proposals generated, ten priority actions were identified through consensus as most important for improving primary health care's response to Romani women in an IPV situation, and these included primary, secondary and tertiary prevention activities.

CONCLUSION

Results indicated that efforts to address this challenge should take an integrated approach that reinforces the primary health care response to IPV in general, while also promoting more specific actions to address barriers to access that affect all Roma women and those who experience IPV in particular.

[Detection of intimate partner violence in primary care and related factors]

OBJECTIVE

Intimate partner violence (IPV) against women is a significant public health and human rights problem. Primary care professionals play a key role in detecting and addressing this issue. The aim of this study is to determine the frequency of IPV and its associated factors in primary care by means of a screening questionnaire and to describe the main actions taken in identified cases.

METHODS

Cross-sectional study in 15 health centres in four autonomous regions of Spain with a total of 265 health professionals. The information was collected through the self-administered PREMIS questionnaire (Physician Readiness to Manage Intimate Partner Violence Survey), which includes variables concerning screening questions, sociodemographic factors, level of training/knowledge about IPV, perceptions and actions. A descriptive and analytical study was conducted.

RESULTS

67.2% of participants said they ask about IPV during consultations. The most frequent actions were: referring patients to other departments, individual counselling and information delivery. ≥21hours of training, an advanced training level, knowledge of policies and programmes and the implementation of an appropriate protocol and reference resources were all factors that increased the likelihood of investigating IPV. The asking of questions increases in line with professionals' perceived level of training in IPV and the provision of a case management protocol.

CONCLUSIONS

Two thirds of health professional respondents said they inquire about IPV. Given the influence of training in IPV and awareness of the resources to address the issue, it is essential to continue investing in the IPV training of healthcare personnel.

[Intimate partner violence. Types and risk in primary care health users in Cancun, Quintana Roo, Mexico]

Objetivo

Identificar la prevalencia y el tipo de violencia de pareja en mujeres usuarias de una unidad de atención primaria y estimar los riesgos para cada tipo de violencia.

Diseño

Casos (incidentes) y controles.

Emplazamiento

Unidad de atención primaria en Cancún, Quintana Roo, México.

Participantes

Mujeres mayores de 18 años con vida en pareja en los últimos 12 meses.

Mediciones principales

Mediante escala para identificación de violencia validada para población mexicana, se evaluó: violencia de pareja total, violencia física, psicológica y sexual. Antecedente de violencia y variables sociodemográficas. Se determinó chi cuadrado para variables categóricas y odds ratio (OR) para la estimación de riesgo.

Resultados

La violencia de pareja total fue del 15,05%, y la violencia psicológica, del 37,3%. En violencia total se observaron diferencias en edad, nivel socioeconómico, estado civil, antecedente de violencia y consumo de alcohol en la pareja (p < 0,05). El riesgo se incrementó en mayores de 40 años (OR: 2,09; IC 95%: 1,07-4,11), antecedente de violencia (OR: 5,9; IC 95%: 2,8-12,44) y consumo de alcohol por parte de la pareja (OR: 12,38; IC 95%: 2,15-29,59). Nivel socioeconómico bajo (OR: 0,384; IC 95%: 0,19-0,74) y estar en unión libre (OR: 0,507; IC 95%: 0,27-0,95) son factores relacionados con menor violencia de pareja.

Conclusiones

La violencia sexual predominó en las usuarias de la atención primaria, y el riesgo de que se presente esta conducta se incrementa con el consumo de bebidas alcohólicas en la pareja y el antecedente de violencia, pero la unión libre y el nivel socioeconómico bajo están relacionados con menor violencia de pareja.

Developing a response to family violence in primary health care: the New Zealand experience

Background

Despite primary health care being recognised as an ideal setting to effectively respond to those experiencing family violence, responses are not widely integrated as part of routine health care. A lack of evidence testing models and approaches for health sector integration, alongside challenges of transferability and sustainability, means the best approach in responding to family violence is still unknown. The Primary Health Care Family Violence Responsiveness Evaluation Tool was developed as a guide to implement a formal systems-led response to family violence within New Zealand primary health care settings. Given the difficulties integrating effective, sustainable responses to family violence, we share the experience of primary health care sites that embarked on developing a response to family violence, presenting the enablers, barriers and resources required to maintain, progress and sustain family violence response development.

Methods

In this qualitative descriptive study data were collected from two sources. Firstly semi-structured focus group interviews were conducted during 24-month follow-up evaluation visits of primary health care sites to capture the enablers, barriers and resources required to maintain, progress and sustain a response to family violence. Secondly the outcomes of a group activity to identify response development barriers and implementation strategies were recorded during a network meeting of primary health care professionals interested in family violence prevention and intervention; findings were triangulated across the two data sources.

Results

Four sites, representing three PHOs and four general practices participated in the focus group interviews; 35 delegates from across New Zealand attended the network meeting representing a wider perspective on family violence response development within primary health care. Enablers and barriers to developing a family violence response were identified across four themes: ‘Getting started’, ‘Building effective relationships’, ‘Sourcing funding’ and ‘Shaping a national approach to family violence’.

Conclusions

The strong commitment of key people dedicated to addressing family violence is essential for response sustainability and would be strengthened by prioritising family violence response as a national health target with dedicated resourcing. Further analysis of the health care system as a complex adaptive system may provide insight into effective approaches to response development and health system integration.

Mechanisms that Trigger a Good Health-Care Response to Intimate Partner Violence in Spain. Combining Realist Evaluation and Qualitative Comparative Analysis Approaches

BACKGROUND

Health care professionals, especially those working in primary health-care services, can play a key role in preventing and responding to intimate partner violence. However, there are huge variations in the way health care professionals and primary health care teams respond to intimate partner violence. In this study we tested a previously developed programme theory on 15 primary health care center teams located in four different Spanish regions: Murcia, C Valenciana, Castilla-León and Cantabria. The aim was to identify the key combinations of contextual factors and mechanisms that trigger a good primary health care center team response to intimate partner violence.

METHODS

A multiple case-study design was used. Qualitative and quantitative information was collected from each of the 15 centers (cases). In order to handle the large amount of information without losing familiarity with each case, qualitative comparative analysis was undertaken. Conditions (context and mechanisms) and outcomes, were identified and assessed for each of the 15 cases, and solution formulae were calculated using qualitative comparative analysis software.

RESULTS

The emerging programme theory highlighted the importance of the combination of each team's self-efficacy, perceived preparation and women-centredness in generating a good team response to intimate partner violence. The use of the protocol and accumulated experience in primary health care were the most relevant contextual/intervention conditions to trigger a good response. However in order to achieve this, they must be combined with other conditions, such as an enabling team climate, having a champion social worker and having staff with training in intimate partner violence.

CONCLUSIONS

Interventions to improve primary health care teams' response to intimate partner violence should focus on strengthening team's self-efficacy, perceived preparation and the implementation of a woman-centred approach. The use of the protocol combined with a large working experience in primary health care, and other factors such as training, a good team climate, and having a champion social worker on the team, also played a key role. Measures to sustain such interventions and promote these contextual factors should be encouraged.

Developing a programme theory to explain how primary health care teams learn to respond to intimate partner violence: a realist case-study

Background

Despite the progress made on policies and programmes to strengthen primary health care teams’ response to Intimate Partner Violence, the literature shows that encounters between women exposed to IPV and health-care providers are not always satisfactory, and a number of barriers that prevent individual health-care providers from responding to IPV have been identified. We carried out a realist case study, for which we developed and tested a programme theory that seeks to explain how, why and under which circumstances a primary health care team in Spain learned to respond to IPV.

Methods

A realist case study design was chosen to allow for an in-depth exploration of the linkages between context, intervention, mechanisms and outcomes as they happen in their natural setting. The first author collected data at the primary health care center La Virgen (pseudonym) through the review of documents, observation and interviews with health systems’ managers, team members, women patients, and members of external services. The quality of the IPV case management was assessed with the PREMIS tool.

Results

This study found that the health care team at La Virgen has managed 1) to engage a number of staff members in actively responding to IPV, 2) to establish good coordination, mutual support and continuous learning processes related to IPV, 3) to establish adequate internal referrals within La Virgen, and 4) to establish good coordination and referral systems with other services. Team and individual level factors have triggered the capacity and interest in creating spaces for team leaning, team work and therapeutic responses to IPV in La Virgen, although individual motivation strongly affected this mechanism. Regional interventions did not trigger individual and/ or team responses but legitimated the workings of motivated professionals.

Conclusions

The primary health care team of La Virgen is involved in a continuous learning process, even as participation in the process varies between professionals. This process has been supported, but not caused, by a favourable policy for integration of a health care response to IPV. Specific contextual factors of La Virgen facilitated the uptake of the policy. To some extent, the performance of La Virgen has the potential to shape the IPV learning processes of other primary health care teams in Murcia.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0899-8) contains supplementary material, which is available to authorized users.

Health sector responses to intimate partner violence: a literature review

BACKGROUND

Intimate partner violence (IPV) is a common and serious public health concern, particularly in South Africa, but it is not well managed in primary care.

AIM

This review aims to summarise the current state of knowledge regarding health sector-based interventions for IPV, their integration into health systems and services and the perspectives of service users and healthcare workers on IPV care, focusing on the South African context.

METHOD

PubMed, CINAHL, PsycINFO and Google Scholar were searched between January 2012 and May 2014. All types of study design were included, critically appraised and summarised.

RESULTS

Exposure to IPV leads to wide-ranging and serious health effects. There is sufficient evidence that intervening in IPV in primary care can improve outcomes. Women who have experienced IPV have described an appropriate response by healthcare providers to be non-judgmental, understanding and empathetic. IPV interventions that are complex, comprehensive and utilise systems-wide approaches have been most effective, but system- and society-level barriers hamper implementation. Gender inequities should not be overlooked when responding to IPV.

CONCLUSION

Further evaluations of health sector responses to IPV are needed, in order to assist health services to determine the most appropriate models of care, how these can be integrated into current systems and how they can be supported in managing IPV. The need for this research should not prevent health services and healthcare providers from implementing IPV care, but rather should guide the development of rigorous contextually-appropriate evaluations.