Challenges to Detecting and Addressing Intimate Partner Violence Among Roma Women in Spain: Perspectives of Primary Care Providers

Abstract

The objective of this study is to identify challenges and facilitators for detecting and addressing cases of intimate partner violence (IPV) against Roma women, from the perspectives of health personnel and representatives of Roma organizations, and to compare both perspectives. A total of 28 semi-structured interviews were carried out between November 2014 and February 2015 in different Spanish cities. A thematic analysis was carried out, guided by Aday and Andersen’s model regarding barriers to access to health services. Both groups signaled the following as principal challenges: (a) consideration of IPV as a private problem among the Roma population, (b) little use of primary care providers for prevention, (c) distrust of Roma women toward primary care professionals as resources for seeking help, (d) the inexistence of Roma professionals in health services, (e) health professionals’ lack of cultural sensitivity related to Roma people, and (f) the focus of health protocols for action against IPV on filing a police report. Potential facilitating factors included Roma women’s trust in nurses, social workers, and pediatricians and ethnic heterogeneity. There is need to promote action to address the identified challenges through a health equity approach that includes greater training and awareness raising among health professionals about Roma culture and the specific needs of Roma women.

Keywords

violence Roma population health professionals health system barriers qualitative research Spain

Introduction

Intimate partner violence (IPV) of men against women is a public health problem that results in a wide range of negative health effects among women and their children. The consequences for women range from murders and suicide attempts to physical lesions and psychological suffering such as depression, anxiety, and loss of self-esteem (Sanz-Barbero, Rey, & Otero-García, 2014; Vives-Cases, Ruiz-Cantero, Escribà-Agüir, & Miralles, 2011). These consequences generate a greater demand for health services, especially Primary Health Care facilities (World Health Organization [WHO], 2013). In Spain, battered women seek help from health care providers more than from other services like the police or services for battered women (Montero et al., 2012). Health systems are responsible for detecting and responding to cases of IPV, in coordination with other resources to support women in being free from violence (WHO, 2013). Primary health care centers constitute the entrance to the Spanish health system. Multidisciplinary teams work within these centers, integrated by family doctors, nurses, midwives, pediatricians, and social workers (in most centers). In selected centers, other professions will also be integrated, that is, physiotherapists, psychologists, or obstetricians. Health delivery is sectorized, and every person/family is assigned to one primary care center and one family doctor.

The risk of experiencing IPV and the opportunities to end a violent relationship are unequally distributed among women. Roma women face situations of vulnerability and social exclusion in terms of health, which is associated with a greater risk of IPV and extremely violent situations (La, Parra, Gil-González, & Jiménez, 2013). Furthermore, IPV among the Roma population is invisible, given the scarcity of studies both in Spain and in other countries. Despite it has no reliable statistics on domestic violence, the few studies available suggest a worrying situation of IPV among Roma women (Prava za sve & Inicijativa i civilna akcija, 2011; Tokuc, Ekuklu, & Avcioglu, 2010).

Roma people are the largest ethnic minority in Spain. As in Europe, the Roma population tend to experience situations of social marginalization, living in ethnic enclaves, facing low education levels, high unemployment, and poor living and health conditions (Fernández-Feito, Pesquera-Cabezas, Gonzalez-Cobo, & Prieto-Salceda, 2017; Jackson et al., 2017; Janevic, Jankovic, & Bradley, 2012; La Parra Casado, Gil Gonzalez, & de la Torre Esteve, 2016; Sandor et al., 2017). The Spanish National Health System (NHS) is a public and universal health system that covers all the Spanish population, including the Roma population (given they have Spanish nationality), as well as the immigrant population with legal status (Spanish Government, 1986, 2018a). Law 1/2004 on integrated protection measures against IPV designates “special consideration for women who for personal or social reasons could be at greater risk of gender-based violence, such as immigrant or ethnic minority women facing social exclusion or disabled women” (Spanish Government, 2004). Despite the mention of this protection for ethnic minority women that appears in the text of the law, measures for application have not been implemented (e.g. there are no protocols or recommendations that address this question). Also, the NHS lacks experience in provision of health services to ethnically diverse groups (García-Ramírez, Lizana, & La Parra, 2017).

The Spanish law is characterized by an integrated and coordinated response on the part of the NHS in terms of detection of cases and attention to women facing IPV, due to recognition of the chronic and severe nature of IPV in terms of the long-term impact on health (Ortiz-Barreda, Vives-Cases, & Gil-González, 2011). Primary care professionals (PCP)—family physicians, nurses, midwives, and social workers—generally have more opportunities than other professionals to detect and address cases of IPV, given their daily contact with women potentially affected who seek health services (Goicolea, Mosquera, et al., 2017).

According to Aday and Andersen’s model (Aday & Andersen, 1974), the access to health services and the use of services by at-risk population groups is influenced by social inequality, meaning that factors related to context, politics, provider characteristics, and characteristics of the actors influence access to care. To our knowledge, there are no previous studies on the specific challenges faced by Roma women affected by IPV from the perspectives—both internal and external—of Roma women themselves and health professionals involved in IPV care. Greater knowledge in this area could help to improve the quality of care provided to Roma women as possible victims of IPV and the development of more effective strategies for health care policy and practice.

The objective of this study is to identify challenges and potential facilitators in regard to detecting and attending to cases of IPV among Roma women, from the perspectives of health professionals and representatives of Roma organizations, and to compare both perspectives.

Methods

Design

The interviews included in this study belong to a larger qualitative study on the response of PCP to IPV that affects Roma women in Spain (Vives-Cases, Espinar-Ruiz, et al., 2017, Vives-Cases, Goicolea, et al., 2017; Briones-Vozmediano, La Parra-Casado, & Vives-Cases, 2018). The larger project aimed to (a) analyze primary health services’ and professionals’ readiness to manage violence against Romani women in Spain and (b) propose improving strategies, taking into account the health professionals’ and Romani women activists’ perspectives.

Sample

Fifteen PCPs (13 women and two men; six family doctors, three midwives, three sexologists, two social workers, and one pediatrician) and 13 female volunteer activists (10 Roma and three non-Roma) from Roma associations (Roma organizations, Roma women’s groups, and feminist groups of Roma women) were interviewed between November 2014 and February 2015 in seven Spanish regions (Valencian Region, Murcia, Castilla-León, Galicia, Andalucia, Asturias, and Madrid) where 64.06% of the Roma population in Spain live (Ministry of Health and Social Affairs and Equality, 2016). Selection of the participants was intentional, according to the capacity to contribute to the research question because of their direct role in implementing IPV health programs and policies. Contacts came from a previous research project about the health system response of IPV in Spain (Goicolea et al., 2013) and through snowball sampling.

Data Collection

Interviews were carried out by the first author and a research assistant trained in qualitative methodology, at work sites of the participants or via phone. A guide was developed with semi-structured open questions, based on a prior literature review and the research questions of the project (Boxes 1 and 2, Supplemental Material). The guide was adapted to the experience of both groups of participants, a pilot test was carried out with three participants from each group, and the guide was flexible in terms of the addition of new questions that might emerge during the interviews.

Interviews lasted approximately 60 min, and interviews were carried out until saturation was reached, understood as the point at which no new information to answer our research questions emerged (Charmaz, 2006). All interviews were audio recorded, with prior informed consent of the participants, ensuring the confidentiality and anonymity of the participants’ personal data. The study was approved by the ethics committee of Alicante University.

Analysis

The first and second authors carried out the thematic analysis (Braun & Clarke, 2006) of the literal transcriptions of the interviews, inspired by Aday and Andersen’s model (Aday & Andersen, 1974). This model is useful for evaluating the effect of social inequality on access to health services and the use of services by at-risk population groups, involving five dimensions: characteristics of the at-risk population, use of health services, user satisfaction, health system characteristics, and health policies.

Both authors read the interviews completely, and in a deductive way, identified the phrases or paragraphs related to barriers or potential facilitating factors for Roma women to abandon violent relationships, attend health services or seek out help, and bring cases of IPV to the attention of PCP. In a next inductive step, text fragments were assigned emerging codes summarizing their content. Finally, these codes were grouped into the five predefined topics according to Aday and Andersen’s model. Atlas.ti-8 qualitative analysis software was used to organize information and help in the coding process.

Results

The information provided by PCP and activists from Roma associations (hereafter referred to as professionals and activists) were classified and interpreted based on the five dimensions described previously (Table 1).

1. Characteristics of the at-risk population: “Do you have to bear it because he’s your husband?”

Table 1.

Types of Challenges Identified in the Interviews Classified in Five Themes According to the Aday and Andersen Model.

Theme	Health professional	Associations
1. Characteristics of the at-risk population	Control by husbands
	The perception of IPV in the Roma culture as a private problem that should not be dealt with outside the community.
	Lack of information about the role of health services in providing support for cases of IPV.
	Cultural normalization of IPV among Roma women.	Resignation
	Fear of the consequences of revealing IPV—family dishonor, loss of children, not being understood.	Silencing of IPV as a sign of respect for family and community.
	Family pressure/community pressure	Self-pressure
	Thinking that there is greater prevalence	Underdiagnosis
2. Use of health services	Irregular use and other health problems
	Thinking Roma women do not want help.	Solutions available within the community.
	Fear of the women.
3. Health system characteristics	Prejudices of the professionals about Roma women.
	Professionals’ lack of cultural sensitivity.
	Ethnic homogeneity
	Structural problems that make intervention difficult.	Lack of professional effort.
4. User satisfaction	Perception of prejudice among professionals or feelings of discrimination.
	Projection of distrust	Perception of hierarchy
		Lack of trust in the relationship with women.
5. Health policy	The IPV protocol is based in part on injury and filing a police report.
	Health programs that do not consider the reality of the Roma population.	Policies that do not consider the reality of the Roma population.
	Lack of awareness raising about the situation of Roma people in the design of training for health personnel.	Lack of awareness raising about the situation of Roma people in the design of campaigns aimed at the general population.

Note. IPV = intimate partner violence.

Professionals estimate a greater prevalence of IPV among Roma couples due to supposedly greater levels of machismo and gender inequality. Activists believe that IPV is similar in Roma and non-Roma couples, but that there is an underdiagnosis of the problem among Roma women, who do not often file police reports:

I think it goes unseen, that there is much more violence than we think within the Roma community. (Provider 18, General Practitioner, woman)

The difference is that there are a number of official complaints, a higher number in one case compared to the other. I believe that this lack of police reports shows a problem, a problem related to reaching women, and I think that gender violence is equally existent in both Roma women and non-Roma women. (Roma activist 10, woman)

Professionals and activists coincide in the belief that there is a certain cultural normalization of violence among Roma woman that would make it difficult to identify situations of violence and that IPV is treated as a private issue:

For her it’s normal, it has been normalized. Also, what seems to me “normal,” the fact that “that’s how he is, like the rest of the men, just like my parents, mi brothers, how they’ve been and how they are.” So it’s even more normalized. (Provider 11, Social Worker, woman).

You have to bear it because he’s your husband. It’s normal for him to smack you. Oh, well, we’ve all managed to handle it honey ( . . . ) that’s a part of being a Roma woman, right? In other words, “if your husband hits you, you have to take it,” so of course, it’s very difficult to identify. (Roma activist 2, woman)

Both groups consider that the extended family influences the decision of Roma women in remaining with perpetrators. Professionals assume that Roma women fear violent repercussions of their husbands—which could pose an added risk—and violent confrontation between families, whereas the activists explain women put honor and family wellbeing before their own wellbeing:

/ . . . / there are many in the family clan, but there is a clear hierarchy, which maybe also happens in the family, in the household, in a couple and in terms of power relationships, it stays there and no one has any opinion about it, no one can get involved in what’s happening. (Provider 2, General Practitioner, man)

We Roma women we sacrifice a lot, they sacrifice, and I told you at the beginning, we would die before letting this affect our home / . . . / these sacrifices we make that sometimes mean we give up our lives to protect others, but you don’t protect yourself. So of course, you live for others, and you don’t live for yourself then. And this is something that Roma women, we know very well. (Roma activist 2, woman)

2. Underuse of health services and irregular use of care

Both groups identify as challenges to care the fact that Roma women do not use health services in a preventive way (e.g. they use sexual and reproductive health services only for delivering) and that they understand their health as an absence of illness. They understand that Roma women do not use regularly health services when they suffer from other health problems, so they do not identify health services as a help resource either for IPV:

Often they go in for rapid consultation, the fast solution, much more than other types of things, no? I don’t know if it’s because they have a different understanding of their health. (Provider 2, General Practitioner, man)

The Roma population has a different understanding of health. When you’re healthy you don’t go to the doctor for any reason at all, and when you are sick, you go to the emergency service? Or you look for health, support and advice within your own family. (Roma activist 9, woman)

Regarding the barriers that Roma women face in seeking health services for a situation of IPV, health professionals identify, primarily, the fear of declaring the situation due to the potential consequences for their husbands (law enforcement and legal mechanisms), including family dishonor or the threat of losing their children. Activists add to this the lack of social and family support structures, combined with family dynamics that perpetuate abuse as well as promote women staying in abusive relationships:

They don’t want you to notify the police so their husbands wont’ go to jail, and lead to the ruin of the woman and her family. (Provider 16, General Practitioner, woman)

Sometimes even their parents tell them, “no, you have to go with your husband,” but what does the woman do, without family support, without support, of course she has to just bear it. So, they don’t dare to take the steps because they know they aren’t going to have support and the family is not going to understand. And let’s not even mention filing a police report. What for? (Roma activist 2, woman)

Both explain that instead of accessing to support services, these women go to Roma community or their own family mechanisms such as “Roma mediation”:

First, because I understand that among Roma people family problems are resolved in the context of the community or the family, and taking these problems outside of the community or family context is a problem, it’s not done directly. (Provider 2, General Practitioner, man)

Very private, very personal, and well, if the women can’t resolve it by themselves they’re always going to go to a family member. They always / . . . / recur to family before a professional. (Roma activist 4, woman)

3. Characteristics of the health system: ethnic homogeneity

Both groups of informants criticize the ethnic homogeneity of health personnel—given that the presence of Roma health professionals is uncommon—the existence of prejudices among professionals, and the lack of time to detect cases and develop trust among the women:

Nor is there an integration in this way, we don’t have people of the Roma ethnicity in our professional sector, which would help us really understand the way they express things or the rituals they have. (Provider 2, General Practitioner, man)

What is it that’s wrong? From within the institutions, and from the programs that address violence, etc., if you don’t have Roma workers it will be difficult for Roma women to have access to these services. Why? Because if even non-Roma women have difficulties in accessing services, and if it requires a lot of work for non-Roma women, imagine how difficult it will be for a Roma woman. (Roma activist 6, woman)

4. Roma women’s dissatisfaction with a system perceived as distant

Professionals and activists coincide in their perceptions of prejudice and/or discrimination among PCP that generate distrust among Roma women, and consequently, prevent them from considering PCP as a resource for help with IPV. Professionals suggest rejection on the part of women, and the activists explain that it is because women feel a sense of hierarchy and superiority from health services that put them at a distance, for example, when they do not use their language:

the health system is closer to non-Roma women than to Roma women in the sense that Roma women do not have as much trust in the health system. (Provider 25, General Practiotioner, woman)

It’s the doctor with superior information, difficult language, and the person doesn’t participate in any way. So then the doctor tells the patient, “you have to do this and this and this,” without involving the user ok? / . . . / this is the issue of hierarchy. (Roma activist 7, woman)

5. Health policies: “Where are the police reports of Roma women?”

Both groups criticize that the IPV service protocol is directed toward filing a police report, and this is required to be granted certain services, and Roma women do not consider filing a report:

the protocol we non-Roma women have, is our protocol on this issue something that is going to convince Roma women? (Provider 2, General Practitioner, man)

The protocol doesn’t work for Roma women, it doesn’t work for them / . . . / for example, a woman isn’t going to pick up the phone and call [to the help assistance] I don’t think she would ever do that. (Roma activist 6, woman)

They also criticize the lack of multicultural training of health personnel and the lack of cultural sensitivity of the IPV health care programs that omit cultural differences and are not specifically adapted to cultural diversity, in this case the Roma population:

They don’t tell us or teach us, we don’t learn in our departments or in our residencies in the hospitals. We leave knowing everything except how to treat people, especially people in so called delicate situations. (Provider 12, General Practitioner, woman)

What they’re doing is treating them according to the generic protocol / . . . / from a cultural point of view, I think it would be helpful to include knowing about the contexts of Roma women in professional training. I think this would complement and even facilitate or result in a better response. (Roma activist 10, woman)

The activists denounce that both the IPV protection policies (including the processes for making a declaration about IPV, protection measures such as a restraining order or isolating women and having them leave the community) and prevention campaigns are ineffective. They indicate that these should be adapted to the reality of Roma women in the context of their culture and language:

The programs could be better adapted to different people, because it is not, it seems like the whole Spanish population is the same. And it could be that a Roma person doesn’t identify with how the programs are presented. (Provider 17, General Practitioner, Woman)

It’s always a White woman, and the relationships are heterosexual. Roma women are never seen in these campaigns. For a campaign it’s normal, how would you say, it’s very White-centered. (Roma activist 5, woman)

6. Potential facilitators: trust and proximity

Professionals and activists identify nurses, midwives, pediatricians, and social workers as potential sources of access to Roma women, because of their ability to inspire trust and their closer and less hierarchical relationship with patients:

Pediatrics or pediatric nursing is important. And the social worker, well, when they know me and I’m not a threat, well, sometimes they come to me often. Because the social worker is often associated with, well, that we may take their children away. (Provider 11, Social Worker, woman)

[They see] nurses as closer to them, they always say it, no? “What if I tell the nurse,” because they see the nurse as a person that is closer to them, more, well, you know? And they see the doctor as someone who is superior / . . . / Because there’s always respect, you know? And there’s proximity with the nurses. (Roma activist 12, woman)

Furthermore, activists highlight the need for mediators, health agents, and Roma professionals to support treatment among equals:

Strategies are needed, among people who have worked with Roma women, creating strategies so that they can say “help me, I’m in this situation,” if not, they’re not going to do it / . . . / I think that you . . . there has to be Roma women within these programs. If not, it’s very difficult Very difficult. (Roma activist 6, woman)

Discussion

Health professionals and representatives of Roma associations coincide in identifying challenges related to the characteristics of Roma women (fear), their use of health services (distrust), their level of dissatisfaction with the treatment received (perception of stereotypes), the characteristics of the health system (ethnically homogeneous), and health policies (an IPV protocol that emphasizes filing a police report). More specifically, the professionals tend to emphasize the challenges related to the characteristics of Roma women, their use of health services, and their dissatisfaction with the treatment received, while the representatives of the associations interviewed emphasize the characteristics of the health system and health policies. In terms of the facilitators, both groups have identified professionals from the fields of nursing, pediatrics, and social work as the most ideal for helping Roma women who might experience IPV, given that the women feel closer to them thanks to a lower level of hierarchy, compared with those that are perceived as an authority or a threat.

In the international context, the potential role of social workers is recognized, and in Spain PCP have more time available for each case than other health professionals (Goicolea, Hurtig, San Sebastian, Vives-Cases, & Marchal, 2015). Without a doubt, a multi-disciplinary and coordinated PCP team would be needed to make it possible to offer an integrated response to IPV (Goicolea, Marchal, et al., 2017; Goicolea, Mosquera, et al., 2017). Furthermore, the activists highlight the need for ethnic heterogeneity among health personnel. The distrust of Roma women described by both groups of participants can be explained by the unequal power relationships between non-Roma health professionals and Roma women, which highlights the difference between their ethnicities and socioeconomic status (Sweeney & Matthews, 2017). The main population group in Spain, the non-Roma Spaniards, is primarily composed of White middle and upper class, working class, established by nationalism, ethnocentrism, and eurocentric culture (Fundación Secretariado Gitano, 2018). The professionals to point out a position of privilege and authority that makes the women feel underprivileged in terms of the hierarchy, which is a barrier to women’s trust of the professionals. It is known that women who belong to ethnic minorities experience discriminatory and abusive practices when they seek care at public health services (Del Pino, Coates, Milton Guzmán, Gómez-Salgado, & Ruiz-Frutos, 2018; McFadden et al., 2018). These experiences reflect not only the low quality of the health services but also the way that the health system reflects discrimination and stigmatization in its practices and transfers them to the Roma population in the doctor–patient medical encounter as a reflection of power relationships (Amroussia, Hernandez, Vives-Cases & Goicolea, 2017). It could be that Roma women perceive all non-Roma professionals as part of the same institution, distant from their community, and they might feel threatened by not knowing the level of coordination between health services and law enforcement services related to their fear of filing a report with the police. These findings align with a similar study in Bosnia and Herzegovina, which identified as the reasons why Roma women rarely report violence or seek assistance the perceived low levels of help-seeking—due to previous bad experiences with the institutions they turned to for protection and assistance—lack of knowledge about the law and protection mechanisms, fear, and shame (Prava, 2011).

The results have shown that both health professionals and activists indirectly make Roma women responsible for deciding to remain in a violent relationship and/or become victims of the cultural normalization of violence. This justification corresponds to a victim-blaming attitude (Ivert, Merlo, & Gracia, 2018). The fact that PCP consider the Roma community to be on one hand, patriarchal and machista—in which IPV is normalized and accepted and Roma women are passive and “don’t want help”—and on the other hand, impermeable to external influences could itself be a barrier to professional involvement in the detection of cases and provision of information on support available to women (Briones-Vozmediano, Goicolea, Ortiz-Barreda, Gil-González, & Vives-Cases, 2014). Relationships of power are not only reflected in prejudices toward the Roma community but also reflected in the tendency to believe that cultural aspects of the Roma community normalize IPV and restrict the agency of women (Francoli Sanglas & Camarasa Casals, 2012). The practices of health professionals are complex phenomena determined not only by their own characteristics and beliefs but also by factors related to the organization of the health system (Amroussia et al., 2017).

The professionals put more emphasis on the differences between Roma women and non-Roma women, in line with professionals from other European countries that subtly construct the marginalized Roma culture (Powell, 2011). This would explain why outsiders perceive the other as having more violence within their community, particularly from White service providers of racialized groups.

The fear of “otherness,” or what is different, by professionals materializes in the lack of comfort recognized by the group in terms of treating people of Roma ethnicity (Charles, 2016; Tulumello, 2016). The power relationships are inverted when professionals fear reprisals in their treatment of IPV cases in Roma women. The fact that PCP consider Roma men to be especially dangerous is a barrier to detecting and treating possible cases of IPV.

Activists have highlighted the need for Roma women to be treated as equals by PCP, which coincides with the term “cultural safety” that orients health services to meet the needs of ethnic minority patients by guaranteeing the quality of treatment (Hole et al., 2015). Positive and culturally safe experiences are those interactions that are friendly and respectful and take into account the feelings of those who seek care, with the provision of active listening and the time needed to ensure a person’s wellbeing (Hole et al., 2015). This is complicated by the fact that currently PCP complain of the lack of time, due to reductions in personnel due to institutional budget cuts and the consequent increased patient–provider ratio (Otero-García et al., 2018). Respectful care that takes into account individual needs implies offering care focused on each woman (Lévesque, Hovey, & Bedos, 2013; Morgan & Yoder, 2012) and her objectives, accounting for the fact that cultural factors influence decisions about information to disclose. Cultural factors can also interact with disparities faced by racial and ethnic minority groups within the health system (Williams, Gonzalez-Guarda, Halstead, Martinez, & Joseph, 2020).

The invisibility of IPV among Roma women is recognized by both groups, although activists consider this a general characteristic of IPV, according to the tip of the iceberg concept: the cases detected and registered are only a small part of the problem, mostly involve physical violence and the most severe cases (Vives-Cases, Álvarez-Dardet, & Caballero, 2003). Violence against women is a structural problem that is the basis of gender inequality and affects all women because they are women. However, when this violence encounters other axes of inequality such as ethnicity—and social class—there are situations of greater vulnerability that make it even more difficult for a woman to escape from a violent couple relationship (Crenshaw, 2006). Racism is also a structural problem that affects the response that these women receive from the health system. Despite the fact that the legislation and the accepted social discourse expressly prohibit discrimination and avoid and censure discourses on racial superiority, explicitly anti-Roma discourses are still common in Spanish society and health institutions. This old-style racism combines with the so-called “new racism,” cultural racism, or postmodern racism (Flecha, 2010; Van Dijk, 1992), which focuses on cultural differences between the majority group and minority groups such as Roma people.

Both groups criticized the fact that the health system protocol for attending to cases of IPV is oriented toward filing a police report, which is required for access to certain resources such as shelters or reintegration support services. This requirement is a barrier to access to services for Roma women, given that these women avoid reporting but need an effective and safe alternative to be able to leave a violent relationship with their children (Kim & Gray, 2008; Sweeney & Matthews, 2017). Recently, there has been a change in the norms for integrated support for victims of gender violence in Spain, through the approval of Royal Decree Law 9/2018 of August 3, on urgent measures for the development of the State Pact Against Gender Violence, which modifies Organic Law 1/2004 (Spanish Government, 2018b). The main change concerns public social services, legal, psychological, and social support services for women exposed to IPV and shelter services for victims of gender violence, which now certify the condition of being a victim of gender violence without the requirement of filling an official complaint. This could be considered a facilitating factor in terms of the access of Roma women to resources.

Limitations

Among the limitations, the purposive sampling method could lead to a selection bias. Selected health providers were expected to be more sensitive to women’s needs, including Roma women, based on their experience dealing with IPV, meaning that having included other professionals who are not working in IPV programs could have brought different results, and the same with other Roma women not belonging to feminist activist groups.

Different measures were taken in this study to guarantee trustworthiness (Lincoln & Guba, 1985). Triangulation of researchers from different disciplines was used to improve the credibility of the study, with the participation of two of the authors in different phases of the design of the protocol and analysis of the results. To strengthen transferability of this study, we included a detailed context of the study, and to improve reliability, the study adopted an emergent design throughout the research process. To support confirmability, an inductive approach was used that implied a process of open coding not conditioned by prior knowledge about the study phenomenon. Literal citations were also used as a way to improve trustworthiness.

Conclusion

Health professionals and Roma activists coincide in identifying challenges to access to PCP for Roma women experiencing abuse, related to the characteristics of Roma women (fear, lack of trust based on the unequal power relationships between non-Roma health professionals and Roma women), the use of health services (dissatisfaction with the treatment received, perception of stereotypes, health system, and health professional characteristics (ethnic homogeneity) and policies (IPV protocol)). Current policies maintain inequalities, so it is important to support actions to address the challenges identified and to strengthen the potential facilitators (the role of nurses, social workers, and pediatricians, ethnic heterogeneity, and a focus on health equity), including training and raising awareness among health professionals about the Roma culture and Roma women’s needs. Training on IPV for health care professionals has been ongoing in Spain since the approval of the 2004 Law. However, it has not reached all professionals, is not yet incorporated in the curricula of all undergraduate health sciences degrees, and the implementation of training programs has been very much dependent on political changes. In addition, such training programs have very seldom considered the added vulnerability of minority ethnic groups, such as Roma women.

Supplemental Material

Box_1_y_2 – Supplemental material for Challenges to Detecting and Addressing Intimate Partner Violence Among Roma Women in Spain: Perspectives of Primary Care Providers

Supplemental material, Box_1_y_2 for Challenges to Detecting and Addressing Intimate Partner Violence Among Roma Women in Spain: Perspectives of Primary Care Providers by E. Briones-Vozmediano, E. Castellanos-Torres, I. Goicolea and C. Vives-Cases in Journal of Interpersonal Violence

Footnotes

Acknowledgements

The authors would like to thank all participants for their contributions.

Authors’ Note

C. Vives-Cases is also affiliated with Department of Community Nursing, Preventive Medicine and Public Health and History of Science, Alicante University, Alicante, Spain and CIBER of Epidemiology and Public Health (CIBERESP), Spain.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The materials and analysis of this study are part of the larger research project titled “Violence against women and the responses of primary health professionals in Spain,” financed by the Ministry of Economy and Competitiveness of the Government of Spain, Carlos III Institute and Fondos FEDER (Ref.PI13/00874), directed by professor Carmen Vives-Cases.

ORCID iD

E. Briones-Vozmediano

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

E. Briones-Vozmediano, PhD, is an associate professor at the Faculty of Nursing and Physiotherapy of the University of Lleida, Spain. Her main research interests are social inequalities in health.

E. Castellanos-Torres, PhD, is a researcher of the Public Health Research Group of the University of Alicante, Spain.

I. Goicolea, MD, PhD, is a professor at the Epidemiology and Global Health Unit of Umeå University, Sweden.

C. Vives-Cases, PhD, MPH, is a professor at the Department of Community Nursing, Preventive Medicine and Public Health and History of Science of the University of Alicante, Spain.

References

Aday

L. A.

Andersen

(1974). A framework for the study of access to medical care. Health Services Research, 9, 208-220.

Amroussia

Hernandez

Vives-Cases

Goicolea

(2017). “Is the doctor God to punish me?!” An intersectional examination of disrespectful and abusive care during childbirth against single mothers in Tunisia. Reproductive Health, 14, 32.

Braun

Clarke

(2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77-101.

Briones-Vozmediano

Goicolea

Ortiz-Barreda

G. M.

Gil-González

Vives-Cases

(2014). Professionals’ perceptions of support resources for battered immigrant women: Chronicle of an anticipated failure. Journal of Interpersonal Violence, 29, 1006-1027.

Briones-Vozmediano

La Parra-Casado

Vives-Cases

(2018). Health providers’ narratives on intimate partner violence against Roma women in Spain. American Journal of Community Psychology, 61, 411-420.

Charles

(2016). Race and recognition: The time of our singing. The American Journal of Psychoanalysis, 76, 140-160.

Charmaz

(2006). Constructing grounded theory: A practical guide through qualitative analysis. London, England: Sage.

Crenshaw

(2006). Mapping the margins: Intersectionality, identity politics, and violence against women of color. Stanford Law Review, 43, 1241-1299.

Del Pino

Coates

A. R.

Milton Guzmán

Gómez-Salgado

Ruiz-Frutos

. (2018). [Ethnicity and health policy: Building equitable solutions in the face of ethnic inequalities]. Revista Espanola de Salud Publica, 26(92), pii: e20180905.

10.

Fernández-Feito

Pesquera-Cabezas

Gonzalez-Cobo

Prieto-Salceda

M. D.

(2017). What do we know about the health of Spanish Roma people and what has been done to improve it? A scoping review. Ethnicity & Health, 24, 224-243.

11.

Flecha

(2010). [Modern and postmodern racism in Europe: Dialogical approach and anti-racist pedagogies]. Reis, 94, 79-103.

12.

Francoli Sanglas

Camarasa Casals

. (2012). EMPOW-AIR: Empowering women against intimate partnership violence in Roma communities—JUST/2010/DAP3/AG/1266 (European Commission). Retrieved from http://ec.europa.eu/justice/grants/results/daphne-toolkit/content/empow-air-empowering-women-against-intimate-partnership-violence-roma-communities_en

13.

Fundación Secretariado Gitano. (2018). [Discrimination and the Roma community 2018. Annual report]. Retrieved from https://www.gitanos.org/centro_documentacion/publicaciones/fichas/125743.html.es

14.

García-Ramírez

Lizana

La Parra

(2017). Migrant Integration Policy Index (MIPEX) Health Strand. Country Report Spain (IOM MHD RO). Brussels, Belgium. Retrieved from https://eea.iom.int/sites/default/files/publication/document/SPAIN_MIPEX_Health.pdf

15.

Goicolea

Vives-Cases

San Sebastian

Marchal

Kegels

Hurtig

A.K.

(2013). How do primary health care teams learn to integrate intimate partner violence (IPV) management? A realist evaluation protocol. Implementation Science, 8(1), 36.

16.

Goicolea

Hurtig

A. K.

San Sebastian

Vives-Cases

Marchal

(2015). Developing a programme theory to explain how primary health care teams learn to respond to intimate partner violence: A realist case-study. BMC Health Services Research, 15, Article 228.

17.

Goicolea

Marchal

Hurtig

A.-K.

Vives-Cases

Briones-Vozmediano

San Sebastián

(2017). Why do certain primary health care teams respond better to intimate partner violence than others? A multiple case study. Gaceta Sanitaria, 33, 169-176.

18.

Goicolea

Mosquera

Briones-Vozmediano

Otero-García

García-Quinto

Vives-Cases

(2017). Primary health care attributes and responses to intimate partner violence in Spain. Gaceta Sanitaria, 31, 187-193.

19.

Hole

R. D.

Evans

Berg

L. D.

Bottorff

J. L.

Dingwall

Alexis

. . . Smith

M. L.

(2015). Visibility and voice: Aboriginal people experience culturally safe and unsafe health care. Qualitative Health Research, 25, 1662-1674.

20.

Ivert

A. K.

Merlo

Gracia

(2018). Country of residence, gender equality and victim blaming attitudes about partner violence: a multilevel analysis in EU. The European Journal of Public Health, 28(3), 559–564.

21.

Jackson

Bedford

Cheater

F. M.

Condon

Emslie

Ireland

. . . Mytton

(2017). Needles, Jabs and Jags: A qualitative exploration of barriers and facilitators to child and adult immunisation uptake among Gypsies, Travellers and Roma. BMC Public Health, 17, Article 254.

22.

Janevic

Jankovic

Bradley

(2012). Socioeconomic position, gender, and inequalities in self-rated health between Roma and non-Roma in Serbia. International Journal of Public Health, 57, 49-55.

23.

Kim

Gray

K. A.

(2008). Leave or stay? Battered women’s decision after intimate partner violence. Journal of Interpersonal Violence, 23, 1465-1482.

24.

La Parra

Gil-González

Jiménez

. (2013). Social exclusion processes and the health status of the Roma people in Spain. Gaceta Sanitaria, 27, 385-386.

25.

La Parra Casado

Gil Gonzalez

de la Torre Esteve

. (2016). The social class gradient in health in Spain and the health status of the Spanish Roma. Ethnicity & Health, 21, 468-479.

26.

Lévesque

Hovey

Bedos

(2013). Advancing patient-centered care through transformative educational leadership: A critical review of health care professional preparation for patient-centered care. Journal of Healthcare Leadership, 5, 35-46.

27.

Lincoln

Y. S.

Guba

E. G.

(1985). Naturalistic inquiry (Vol. 75). London, England: Sage.

28.

McFadden

Siebelt

Gavine

Atkin

Bell

Innes

. . . MacGillivray

(2018). Gypsy, Roma and Traveller access to and engagement with health services: A systematic review. European Journal of Public Health, 28, 74-81.

29.

Ministry of Health and Social Affairs and Equality. (2016). Study-map on housing and the Roma population, 2015. Retrieved from http://www.mscbs.gob.es/ssi/familiasInfancia/PoblacionGitana/docs/anexo2mapaviviendapoblaciongitana.pdf

30.

Montero

Ruiz-Pérez

Escribà-Agüir

Vives-Cases

Plazaola-Castaño

Talavera

. . . Peiró

(2012). Strategic responses to intimate partner violence against women in Spain: A national study in primary care. Journal of Epidemiology & Community Health, 66, 352-358.

31.

Morgan

Yoder

L. H.

(2012). A concept analysis of person-centered care. Journal of Holistic Nursing, 30, 6-15.

32.

Ortiz-Barreda

Vives-Cases

Gil-González

(2011). Worldwide violence against women legislation: An equity approach. Health Policy, 100, 125-133.

33.

Otero-García

Briones-Vozmediano

Vives-Cases

García-Quinto

Sanz-Barbero

Goicolea

(2018). A qualitative study on primary health care responses to intimate partner violence during the economic crisis in Spain. European Journal of Public Health, 28, 1000-1005.

34.

Powell

(2011). Gypsy-Travellers and welfare professional discourse: On individualization and social integration. Antipode, 43, 471-493.

35.

Prava

sve

& Inicijativa i civilna akcija. (2011). Report within the project: Roma women for like without violence. Response of institutions to domestic violence. Sarajevo: International Council of Voluntary Agencies, Rights for All Bosnia & Herzegovina and United Nations Trust Fund to End Violence Against Women. Retrieved from http://rightsforall.ba/publikacije-en/docs-en/Roma_Women_For_Life_Without_Violence-ENG.pdf

36.

Sandor

Kosa

Boruzs

Boros

Tokaji

McKee

Adany

(2017). The decade of Roma Inclusion: Did it make a difference to health and use of health care services? International Journal of Public Health, 62, 803-808.

37.

Sanz-Barbero

Rey

Otero-García

(2014). [Health status and intimate partner violence]. Gaceta Sanitaria, 28, 102-108.

38.

Spanish Government. (1986). Law 14/1986, of April 25th, General of Health.

39.

Spanish Government. (2004). Law 1/2004 on integrated protection measures against IPV.

40.

Spanish Government. (2018a). Royal Decree-Law 7/2018, of July 27th, on universal access to the National Health Services.

41.

Spanish Government. (2018b). Royal Decree Law 9/2018 of August 3d, on urgent measures for the development of the State Pact against Gender Violence.

42.

Sweeney

Matthews

(2017). Friends, families and travellers: A guide for professionals working with Gypsies, Roma and Travellers in children’s services. Family Friends and Travellers. Retrieved from https://www.gypsy-traveller.org/resource/a-guide-for-professionals-working-with-gypsies-roma-and-travellers-in-children%C2%92s-services/

43.

Tokuc

Ekuklu

Avcioglu

(2010). Domestic violence against married women in Edirne. Journal of Interpersonal Violence, 25, 832-847.

44.

Tulumello

(2016). Us and them: Otherness and exclusion. In Tulumello

, (Ed.), Fear, space and urban planning (pp. 39-53). New York: Springer.

45.

Van Dijk

T. A

. (1992). Discourse and the denial of racism. Discourse & Society, 3, 87-118.

46.

Vives-Cases

Álvarez-Dardet

Caballero

(2003). Violencia del compañero intimo en España [Intimate partner violence in Spain], Gaceta Sanitaria, 17, 268-275.

47.

Vives-Cases

Espinar-Ruiz

Castellanos-Torres

Coe

A. B.

(2017). Multiple struggles in fighting violence against women: Implications among Romani women leaders in Spain. Global Health Action, 10(Supp. 2), 1317084.

48.

Vives-Cases

Goicolea

Hernández

Sanz-Barbero

Davó-Blanes

La Parra-Casado

(2017). Priorities and strategies for improving Roma women’s access to primary health care services in cases on intimate partner violence: A concept mapping study. International Journal for Equity in Health, 16(1), 96.

49.

Vives-Cases

Ruiz-Cantero

M. T.

Escribà-Agüir

Miralles

J. J.

(2011). The effect of intimate partner violence and other forms of violence against women on health. Journal of Public Health, 33, 15-21.

50.

Williams

J. R.

Gonzalez-Guarda

R. M.

Halstead

Martinez

Joseph

(2020). Disclosing gender-based violence during health care visits: A patient-centered approach. Journal of Interpersonal Violence, 35(23-24), 5552-5573. doi:10.1177/0886260517720733

51.

World Health Organization. (2013). Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. Geneva, Switzerland: Author.

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