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

The Setting: IPV and the Spanish Health System

The Spanish health system is highly decentralized. The 17 autonomous regions—with their own Parliament and government—are in charge of health planning, public health, and management of health services. Backed by the “Gender-Based Violence Law,” a “National Commission Against Gender-Based Violence” (NCAGBV) was created within “the Inter-Territorial Council of the National Health System”—the highest body for decision making regarding health issues in Spain, comprising representatives from both the national government and the autonomous regions. The Observatory of Women’s Health, a technical body created within the Spanish Ministry of Health, acts as secretariat of the NCAGBV and gives support to the regional health systems (RHSs) in their actions to implement a health-sector response to IPV (Organic Law 1/2004).

At the RHSs, implementing and monitoring the implementation of the Law is the responsibility of regional delegates to the NCAGBV and civil servants who participate in the technical working groups. From 2004 onward—at different speeds in each RHS—actions were implemented in terms of (a) developing protocols and guidelines to identify the state-of-the-art knowledge and make it available to teams and providers; (b) training of health professionals, aimed at raising the awareness of providers, transferring know-how, and convincing them to respond to IPV; and (c) implementing systems to monitor the implementation of the policy and pressure those responsible for acting. Despite all those measures, few IPV cases are detected in health care facilities, and the weak implementation of monitoring systems further hinders the possibility of accurately assessing progress (Goicolea et al., 2013).

Participants and Data Collection

Individual interviews were conducted from July 2012 to March 2013, with a purposive sample of 26 key informants: 23 from the 17 autonomous regions and three from the national level. Informants were civil servants within the RHSs or at the national level and were in charge of coordinating the health-sector response to IPV. They were all participating—or had participated—in the technical working groups, and some of them had also participated in the NCAGBV. Twenty-four participants were identified by the interviewer as women and two as men. Their backgrounds were medical doctors (14), nurses (4), psychologists (2), midwives (2), anthropologist (1), social worker (1), sociologist (1), and pharmacist (1). One informant per RHS was interviewed, except in some RHSs where another informant was included due to their experience in certain areas of interest to the study. They were all between 40 and 60 years old, although the exact age was not asked for.

First contacts were facilitated through the National Observatory of Women’s Health and subsequently by interviewees themselves, following snowball sampling. The average duration of the interviews was 1 hr; 16 interviews were conducted face to face, while 10 were phone interviews. The interviews were conducted in Spanish by three researchers involved in the project (I.G., E.B.-V., and A.M.). An interview guide was designed by the research team based on the objectives of the study and a review of literature. The guide included predefined themes to explore as well as examples of questions to ask to each interviewee. To allow for flexibility, specific wordings of the questions were deemed less important. The interviews started with an open question encouraging participants to describe how the process of integrating IPV has occurred in their region—or nationally in the case of national-level informants. Afterward, questions were asked to explore the political context and how the integration was organized (see the appendix). This included exploring responsibilities, commissions, coordination, the relationship between the national and regional levels, activities implemented to train health providers, the development of guidelines and protocols, the implementation of monitoring systems, approach to women in situations of vulnerability and preventive actions, and their views on the entire process and their personal involvement.

Data Analysis

All the interviews were held in Spanish, recorded, and transcribed verbatim. Transcripts were imported into the software ATLAS.ti-5 to manage the analytical process. To analyze the interviews, we used the grounded theory method of constant comparisons in accordance with the constructivist approach described by Charmaz (2006). The interview transcripts were read several times, and the original Spanish transcripts were used for the coding process. We conducted the analyses in the following stages: (a) open coding, (b) selective or focused coding, and (c) theory integration (Dahlgren, Emmelin, & Winkvist, 2004). We first conducted an open coding procedure, that is, coding the material line by line. By constantly comparing the codes and integrating groups of codes that referred to a similar topic, some preliminary categories started to emerge. Selective coding followed, meaning that codes were reread and selected to refine the preliminary categories. During this process, codes that were relevant to our research question were selected, and the preliminary categories condensed into three categories and one core category. The core category was chosen based on its centrality, recurrence, and close relationship to the other categories.

As a result of the relations between the core category and the three categories, we developed a conceptual model showing the process of integrating the IPV in the Spanish health system. Afterward, we constructed a situational map to deepen and graphically explain the core category, using the methodology of situational analysis, which is useful to order the social complexity reflected in the discourses through graphically position the concepts implicated in the categories resulting in the core category (Clarke, 2003).

Ethics

Ethical approval was obtained from the Ethics Committee of the University of Alicante. The project was explained to all potential informants, and they were given a form with a written summary of the project. They were assured that their participation was voluntary and that they could withdraw at any moment during the interviews without need to give any explanation. Those who agreed to participate in the interviews and to have their interview recorded signed a written voluntary informed consent. To ensure the confidentiality of the data, documents were anonymized by removing the names of participants and the regions they belong to. Only the research team had access to the collected data.

IPV Is a Complex Issue That Generates Resistance and/or Activism

This category is about dilemmas, confidentiality, personal implication, activism, frustration, resistances, and referral systems, and represents how participants considered IPV different and more complex than other health problems addressed in the health system. During the interviews, the contradiction emerged between the consideration of IPV as an important public health problem and how, because of its complexity, it was seen as beyond the responsibilities and skills of health providers. They based their beliefs about its complexity on the fact that the causes of IPV could not be simplified to biological entities but were strongly rooted on social factors. The requirement for an interagency approach, meaning the involvement of different sectors such as education, police, law, and social services together with the health sector, in a response that covers the diverse and connected needs of women exposed to IPV was also mentioned as part of this complexity.

It’s a complex issue, since it’s an issue that touches upon legal aspects, ethical aspects, skills to conduct a good clinical interview . . . And the complexity of the phenomenon as well, it’s not the same as, for example you tell your patient: “you have high cholesterol levels, I will give you those pills and we will control it,” it’s far more complex that that . . . it means entering into a field that is not as protocolized as other clinical issues. (Informant 21)

Participants expressed that responding to IPV was something new for health providers as they have not received such training during their undergraduate education. In addition, participants considered that dealing with IPV personally affected those dealing with the problem; it conveyed strong ideological, ethical, and moral implications.

It’s a really hard issue, because it evokes personal stories, it forces you to revise a lot of issues, and makes changes in your own attitudes towards many issues. (Informant 5)

An example of this complexity was the ethical dilemma regarding whether to comply with legal requirements of mandatory reporting even when the woman did not agree versus respecting women decision and times even if this could carry legal consequences for the provider.

Interviewed professionals were conscious that getting out of a violent relationship was a very long and cyclic process, where women might make many attempts to get out of the relationship before actually ending it. They pointed out this complex cycle as a source of frustration for the providers, who were considered as being trained for and used to dealing with biomedical health issues with well-defined and obvious treatments.

The connections between IPV and gender further increased resistance, as gender issues were considered as raising opposition from many health providers and politicians. Men health providers’ greater resistance to respond to IPV was a repeated topic throughout the interviews. Interviewees recalled how some men health providers might argue that this was a “women’s issue,” and how, as one interviewed commented, “it always happens with issues of gender and health, that men do not get involved” (Informant 17).

It was clear that IPV is considered a topic that raised opposition and resistance, but at the same time among certain professionals it promotes activism and commitment. Voluntarism arose during interviews as the key element to integrate an IPV response. Most of the interviewees presented themselves as committed to the cause of IPV, pursuing the implementation of this program against political changes and looking for ways to sustain training programs despite funding limitations. They also identified certain professionals both at the highest ranks and in first-line health care services who shared their commitment to this cause:

The advantage that I can see is that the people who are working with those issues [as IPV] are people who really believe in what they are doing, they have a very strong ideological position, and this is important. They are people who can mobilize others, they are enthusiastic, and they are also knowledgeable, but above all this they truly believe in what they are doing, because they can feel the injustices made towards women. (Informant 16)

The Mandate to Integrate a Health-Sector Response to IPV: A Priority Not Always Prioritized

This category is about law, guidelines, protocols, training, institutions, politicians, and funding. Interviewed professionals believed that the Spanish “Gender-Based Violence Law” pushed the public sector to respond to IPV.

Participants mentioned how the efforts of regional governments and the national government were aligned on the issue of IPV. Early experiences of regional health-sector responses to IPV—such as in Cantabria, the Basque Country, or the Canary Islands—served as examples for the development of national guidelines and programs and inspired the efforts of other regions. Participants thought that great efforts had been put on training programs and considered these essential to successfully integrate IPV.

Participants highly valued the structure created within the health system to support the integration of health sector’s response to IPV, namely, the NCAGBV, and the working groups and the Observatory of Women’s Health. Those spaces were considered key in the promotion of this process of sharing and learning between regions.

[The Observatory] has played a key leadership role, it has supported and reinforced the regional efforts. And I do not only mean in terms of funding, which has also been very important, but also in terms of technical support and leadership. Working in groups meant getting all the regions involved. (Informant 8)

Despite the enabling environment created by the Law and promoted by the Observatory of Women’s Health, participants also considered that sustaining the integration of the health sector’s response to IPV was strongly dependent on the willingness of the stakeholders in charge. Changes in political parties in government—both at national and local levels—were cited as hindering IPV integration. Political changes got translated into changes of the managers in charge of the RHSs. This also affected the professionals in charge of IPV integration—who could be fired or assigned to other duties. Participants mentioned how regions that were examples of good practices on health-sector response to IPV were downgraded due to political changes. They considered that actions could have sometimes been carried out without a real commitment from decision makers within the health system. They “went with the flow” pretending to implement the requirements coming from the NCAGBV but not prioritizing IPV.

The current situation of decreased funding to the health sector was pointed out as affecting service delivery, especially in terms of programs that were relatively new and prone to raise opposition, such as IPV.

I told the director: “You will have to give me money for training health providers on IPV,” and he replied: “How many women died here due to IPV?” and I said: “None,” and he said: “Each day 10 people die due to cardiovascular disease. As you shall understand I will put very little money on IPV.” (Informant 2)

The Spanish Health System: Respectful With Professionals’ Autonomy and Firmly Biomedical

This category is about biomedical training, biomedical approach, motivation, and the aggressors. Participants felt that the Spanish health system worked well in general, and health professionals were trusted to do their job. Health professionals had autonomy within their offices, and monitoring systems were not aimed to control their work and/or penalize those not fulfilling certain tasks or achieving certain goals. In terms of IPV, this autonomy also meant that the implementation of the actions contemplated in the protocols and guidelines on health care response to IPV was not enforced and depended strongly on the willingness and interest of each health professional. Participants did not agree regarding the benefits of making professionals’ response to IPV compulsory, and some thought it would be the only way to sustain it, while others felt it would never work.

There are professionals who tell me: “This is an issue that I really dislike” . . . then I told them: “OK, you don’t have to deal with it yourself, there are other professionals who can do it, you are not forced to do it” . . . I think that those cases, taken care of by professionals who do not want to do it, do not work out well. I don’t think that everybody can take care of those cases. (Informant 23)

Participants considered the Spanish health system not ready to deal with nonbiomedical issues, partly because of the biomedical training received by health professionals. The training of medical doctors and nurses during the university years focused on diagnosing and treating diseases, and issues such as IPV were, to their knowledge, absent from the training curricula. Even if some of the interviewees were actively engaged in incorporating the training of IPV within the education of medical graduates, they thought this was achieved due to their commitment and willingness and not enabled by the existing structure.

It’s hard to accept that gender based violence is grounded on gender issues, because gender is something that we have never been taught. I mean, have you seen anything about gender or gender based violence at medical school? We were not taught. (Informant 2)

Participants considered that integrating a biopsychosocial approach into the health system was important but not always possible. Primary health care centers do deal with social problems linked to health problems, but they do so mainly through the social workers who are part of the team. Limited consultation times and other factors hinder other professionals’ capability to respond to social issues connected with their patients’ health problems. As one participant pointed out, integrating a response to IPV could be considered as the first biopsychosocial intervention that has been seriously attempted to be integrated within the health system:

Responding to IPV within the health care system as a public health problem it is an issue in which the biopsychosocial approach is embedded; I mean it has been like a first attempt for shifting the established paradigm of how the medical care should be implemented. It might be that this is the first attempt to implement a comprehensive health care model that accounts for the social as well. (Informant 16)

An additional difficulty that participants mentioned was how primary health care practices are structured in Spain. Family doctors working in primary health care teams in Spain have a quota of patients they are responsible for, and usually members of a nuclear family are assigned to the same doctor. The abusive partners of the women they might see are also their patients. Participants considered that, on one hand, this made it very difficult for the woman to disclose IPV. On the other hand, for family doctors this could be a very stressful situation and could place the professional at risk. Guidelines were not provided on how to deal in those cases, and each professional had to decide on their own how to handle it.

One of the problems is how to take care of both the perpetrator and the victim . . . This is really tricky to do. Sometimes perpetrators will come to his family doctor and blame him: Why have you written this about me? (Informant 9)

Developing Diverse Responses to IPV Integration: Adapting the Health System and/or Adapting IPV

The combination of these three categories led to different responses that are summarized in the core category. A range of responses were possible, from the adaptation of the health system enabling the incorporation of a biopsychosocial approach to health and IPV, to the medicalization of IPV. Figure 2 describes how these responses depend on the health professionals’ personal motivation and the level of institutionalization of the IPV mandate. As a result of the combination of these two factors, four responses to IPV integration are possible, ranging from (a) comprehensiveness—implementing changes in the structure of the health system to ensure a response to IPV that fulfills the WHO guidelines, (b) medicalization—narrowing down the response to make it fit into the biomedicalized health system, (c) optionality—relying on individual choice to respond (or not) to IPV, and (d) avoidance—ignoring the mandate and not offering any actions for women exposed to IPV. Responses were not exclusive; different responses could coexist and overlap.

OPEN IN VIEWER

Figure 2.

Situational map with the possible responses offered to IPV in the National Health System in Spain.

One response was to adapt the health care system to enable a response to IPV that incorporates the actions stated in the WHO guidelines (comprehensiveness). Such a response will imply a complete “change in the system” as one participant pointed out. This response enclosed the attempts to shift the health system’s approach from biomedical to biopsychosocial, which was considered by the participants as the most conducive for integrating a response to IPV.

Participants recalled concrete examples of health care teams incorporating such approach, and as one participant stated, “The model we have to follow is a biopsychosocial model, I say this again and again without getting tired, because this is the only way to understand IPV” (Informant 3). However, they considered that disseminating this approach throughout the entire health system was difficult.

I think that [implementing a biopsychosocial approach] it’s the path we should follow in the health system. We have to change the model, although this will take time, due to the organizational model we have, the health system structure . . . but I think that more and more we have to be well prepared to respond to those demands that are not merely clinical. (Informant 20)

Another possible response was to narrow down what the health care response to IPV would imply, to make it integratable within the biomedical approach hegemonic in the health system (medicalization).

An example of this response, pointed out by participants and attempted in some of the Spanish RHSs, would be that of IPV screening programs. Presenting IPV as something that could be detected through systematically asking all women and labeling this technique as screening might make it more familiar and approachable for health professionals. The integration of IPV management protocols into the electronic clinical records was another example.

Despite the positive effects of these attempts to narrow down the IPV response into something more accessible and familiar for health professionals, participants did not agree on its appropriateness for ensuring an integral response to IPV. Screening and clinical inquiry were not considered paramount by everybody. Protocolized care was also criticized because the response of the health professional when confronted with a woman exposed to IPV was much more complex and unpredictable than following the steps of a protocol. Moreover, even if inclusion of IPV information in clinical records was considered as an advantage compared with the printed forms previously available, confidentiality, ethical and technical issues were identified as problematic during the implementation. As one participant pointed out, the response of women exposed to IPV to routine inquiry and registration actions was not as favorable as professionals might expect, and this confronts professionals with questions not easily answered through protocolized care:

I remember once I detected a case and the woman replied: “now I have two problems: violence and the fact that now I am aware that I am suffering violence.” (Informant 11)

Another type of response would be to skip the structural-level changes and rely on each individual health care provider’s willingness and capability to integrate a response to IPV in their own practice (optionality). On one hand, long-term changes aimed to shift health system’s approach into a biopsychosocial one are difficult to implement and will take time. On the other hand, small adaptations of the health system to integrate isolated aspects of a health care response to IPV are not enough and might be counterproductive. Thus, this third type of response relies on certain professionals with strong commitment and motivation to address the issue of IPV, as well as their ability to disseminate this motivation among others. If the health system managers have enough sensitized and committed professionals, they will be able to implement an adequate response to IPV within their practices and they might even influence their colleagues’ workings:

The personal factor is very important. If there are one or two professionals who are motivated and able to transmit this to others. Because sometimes there is only one expert, who is not able to share with others, and this doesn’t work. (Informant 12)

Finally, as monitoring systems are weak, professionals can entirely avoid integrating any response to IPV in their practice (avoidance). However, as all regions currently have enacted policies and protocols, and implemented diverse interventions, complete avoidance of the topic seems a response very hard to sustain.

Methodological Considerations

We applied the criteria described by Lincoln and Guba (1985) to enhance trustworthiness in qualitative research. Transferability was enhanced by theoretical sampling, selecting participants’ profiles based on their ability to contribute to the research question. Triangulation of researchers and participants involving different civil servants profiles and from different regions was also used to improve credibility. We also made an effort to contextualize the results to help readers evaluate the extent to which our results might be applicable to other similar settings. To enhance dependability, we used an emergent design and responded to constant change, that is, by exploring issues emerging from one interview in the subsequent. For example, one issue that emerged during one of the interviews was the situation that the family doctor faces in dealing with the woman’s partner when an IPV case is detected, because the entire family was assigned to the same family doctor. This did not appear in the first interview guide, but was included in subsequent interviews because we considered that it was an interesting issue. To stay closer to the text, the original Spanish version was used for coding and translation into English only took place once categories and themes had emerged.

Among the limitations, it should be taken into account that (a) in general, the participants were highly motivated people, and the results might be different if primary front-line providers would have been interviewed instead; (b) a social desirability bias could occur among them as the participants are representatives of their institutions; (c) differences between regional and national workers have not been explored; and (d) the differences between autonomous regions have not been further explored in the results. Although the results are not statistically representative of the Spanish health system, they can be used to theorize about the health-sector responses to IPV in Spain and in similar settings from a managerial perspective.

The findings should be interpreted in light of the current global recession, which has prompted a wide range of economic, political, and social reforms in Europe and Spain which have involved cutbacks in social- and health care service investment (De Vogli, 2013; Stuckler, Basu, Suhrcke, Coutts, & McKee, 2011). In Spain, austerity measures have already been implemented in the national health system through cuts in management spending and a freeze on recruitment and salaries (Laparra et al., 2012; Legido-Quigley et al., 2013). This has had a negative impact on IPV services, including on their workers and the service delivered to the women (Briones-Vozmediano, Agudelo-Suárez, Goicolea, & Vives-Cases, 2014). National and regional efforts should focus on promoting health systems that are more person centered and less biomedicalized. In such health systems, it will become easier to integrate a health care response to IPV. To ensure that the health care response to IPV becomes part of routine practice, the health system has to encourage and support health professionals to detect and adequately respond to IPV and develop enabling structures to facilitate their work.