Adaptive work in the primary health care response to domestic violence in occupied Palestinian territory: a qualitative evaluation using Extended Normalisation Process Theory

Abstract

Background A health system response to domestic violence against women is a global priority. However, little is known about how these health system interventions work in low-and-middle-income countries where there are greater structural barriers. Studies have failed to explore how context-intervention interactions affect implementation processes. Healthcare Responding to Violence and Abuse aimed to strengthen the primary healthcare response to domestic violence in occupied Palestinian territory. We explored the adaptive work that participants engaged in to negotiate contextual constraints. Methods The qualitative study involved 18 participants at two primary health care clinics and included five women patients, seven primary health care providers, two clinic case managers, two Ministry of Health based gender-based violence focal points and two domestic violence trainers. Semi-structured interviews were used to elicit participants’ experiences of engaging with HERA, challenges encountered and how these were negotiated. Data were analysed using thematic analysis drawing on Extended Normalisation Process Theory. We collected clinic data on identification and referral of domestic violence cases and training attendance. Results HERA interacted with political, sociocultural and economic aspects of the context in Palestine. The political occupation restricted women’s movement and access to support services, whilst the concomitant lack of police protection left providers and women feeling exposed to acts of family retaliation. This was interwoven with cultural values that influenced participants’ choices as they negotiated normative structures that reinforce violence against women. Participants engaged in adaptive work to negotiate these challenges and ensure that implementation was safe and workable. Narratives highlight the use of subterfuge, hidden forms of agency, governing behaviours, controls over knowledge and discretionary actions. The care pathway did not work as anticipated, as most women chose not to access external support. An emergent feature of the intervention was the ability of the clinic case managers to improvise their role. Conclusions Flexible use of ENPT helped to surface practices the providers and women patients engaged in to make HERA workable. The findings have implications for the transferability of evidenced based interventions on health system response to violence against women in diverse contexts, and how HERA can be sustained in the long-term.

Improving health system readiness to address violence against women and girls: a conceptual framework

“…A novelty of the conceptual framework is the capabilities related to the women and community engagement and the need to also consider how the system can sustainably involve and interact with clients (women) and communities to ensure and promote readiness for integrating change. Without this, other health system capabilities are weakened (as we saw for instance in our findings in relation to low women’s referral uptake [ 44 ]). The inclusion of this dimension was not sufficiently addressed in the initial WHO building blocks model [ 62 ] though subsequently mentioned in the WHO VAW management response [ 15 ].…”

“…With a readiness lens, it is possible to design more tailored interventions that consider facilitators and barriers at different levels of the health system, and that recognise the critical importance of working closely with managers and stakeholders. In addition, our conceptual framework for the readiness assessment has proven useful in highlighting significant systemic issues for developing health system interventions and their evaluation [ 44 ].…”

“…During the second phase of the development, the initial draft framework was reviewed and discussed by researchers of the Healthcare Responding to Violence and Abuse (HERA) study – a mixed-method intervention study that aimed to strengthen the primary care response to IPV in Brazil and Palestine (including all co-authors and 1 advisor [SM]) [ 44 ]. This was to determine if the framework was practical and understandable, and to discuss whether it was necessary to remove or add any element considered redundant or missing.…”

Remote methods for research on violence against women and children: lessons and challenges from research during the COVID-19 pandemic

“…Four studies were linked to violence prevention interventions at the community, school or health facility level. 36–38 Phone interviews were the most frequently used method. Other remote methods included video interviews or online questionnaires.…”

“…We include examples from two longitudinal or cohort studies (the Context of Violence in Adolescence Cohort (CoVAC) study in Uganda 31 and the Maisha Fiti study in Kenya32); one cross-sectional nationally representative survey, established in the late 1980s and carried out approximately decennially (the British National Surveys of Sexual Attitudes and Lifestyles (Natsal) pilot of remote study33); three qualitative studies (the CoVAC qualitative study,34 the Bantwana programme in Uganda35 and the Child-friendly Catholic Schools Study-Zimbabwe (CCSS-Z)); and two mixed methods studies (the HERA - Healthcare Responding to Violence and Abuse study in Brazil and Nepal). Four studies were linked to violence prevention interventions at the community, school or health facility level 36–38. Phone interviews were the most frequently used method.…”