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.

The team gets along well together; they have a room where they gather for coffee breaks and lunch, and there are social activities that they do together. Half of the staff is old, with 15-20 years in the health centre, while half is young.

Salinas
16 Rural Small town of middle low socioeconomic status.
Very good relationship with the community. Three nurses visit the two high schools in the town twice a week and have consultations there on those two days. This has been running for several years now. Currently, one nurse has also started a therapeutic group for women. The medical coordinator works in another health post, and team meetings are not regular. Active team-Facebook page, weekly demonstrations against decreased funding for the public health system.

Indias 13
Rural Small rural village. Professionals working on the team also live in the village or neighbouring villages, and they know their patients as neighbours or friends. Small team that gets along very well together. There are satellite health posts, but all of them meet every Thursday (with the exception of the social worker, who works at another PHC on that day).

Mares 22
Urbanregional capital Located in the city centre, in a middle-high socioeconomic neighbourhood.
In general, there is a good relationship between patients and health care providers.
The person who is now in charge of the IPV program in the RHS worked there some years ago. The centre focuses on curative services, patient-centred approach only among selected professionals, and there are no preventive activities.

LEON
Angeles 26 Urban regional capital Located in the outskirts of the city in a middle low socioeconomic neighbourhood.
Not a strong relationship between the HC and the community. Focus on curative services. There is no medical coordinator at the moment. They mention that beforehand they used to work more as a team, but currently, this is no longer possible due to work pressure (fewer substitutions and fewer staff due to austerity measures).
Avecilla 23 Rural Rural small village with aging population. Population density is low, and people are distributed across a number of small villages with small populations.
The health professionals have to visit several small villages, and the health centre in AG works as a meeting centre. They attend mainly old and very old people, as well as some tourists during the summer. Medical coordinator has a good relationship with the health professionals.
Midwife is a regional trainer on IPV and runs therapeutic groups for women.

MURCIA La Virgen 35
Urban capital Middle-low socioeconomic neighbourhood.
Good relationship with the community; they run a number of community groups where they engage in prevention and health promotion activities. There is team work in this health centre; especially in terms of IPV, there is team work among a number of GPs, nurses, the resident psychologist, the social worker and some paediatricians. Midwives are not involved. Health centre with a strong PHC approach (a role model for this in the region and beyond). Also actively involved in training programme on the women's malaise approach. Several team members acknowledged regionally as experts on IPV response.

El Campo 21
Rural Health centre in a rural agricultural area. Small town where people know each other, which makes it more difficult to disclose cases and file denounces.
Good relationship with patients. They know each other. Social worker very motivated and an expert on IPV (previously in charge of that programme within the RHS), and also a midwife and one GP. Biopsychosocial approach used by many GPs, less among nurses. Social worker and midwife implement a women's malaise group, and they have been involved in developing different plans and protocols related to IPV at the regional level. Mora 33 Rural 1 slightly larger HC and satellite health posts.
People go to the HC due to biological problems, and it is difficult for them to consider going to the HC to disclose IPV. There is not a team style of responding to IPV; each professional does the best that he/she can. They do not share information about those cases. The majority consider responding to IPV as responding to obvious cases, but not as the early detection of cases.
Since they have good relationships with patients, issues of IPV might be mentioned directly by women, especially physical IPV, and they will issue legal reports, recommend denouncing and/or refer to the social worker.
Cristina 32 Urban capital High-middle class neighbourhood.
No team work in this health centre. One of the persons who is an expert on IPV and who is currently working at the managerial level in Murcia was a GP in this centre. Many acknowledge her as a key person regarding this topic, but her expertise has not been inherited by any of the professionals currently working in Cristina. This is also a health centre where women and children who are in shelters come to be attended. Social worker and sexologist are very active in working on issues related to violence against women. They have a women´s group and a group with women who have been victims of sexual abuse There is a reference network between the health centre, the police, the municipal services and the judicial system to support women who have been exposed to IPV.
Naranjo 28 Urban regional capital Medical coordinator is an expert on IPV. She teaches other health professionals about this topic in the autonomous region and also teaches medical students at the University. At this health centre, there is also a very active group pf physicians who do research on cardiovascular diseases, including clinical trials.