Background
Defining context and complexity
Context in Palestine
Methods
Aims of the study
Implementation theory
Description of the intervention
Settings and ethics
Study design and data collection
Women | N = 5 |
Clinic | |
1 (Area C) | 3 |
2 (Area B) | 2 |
Age range | 20 to 30 years |
Length of marriage | 14 months to 11 years |
Number of children | 1 to 5 |
Education | |
Secondary school | 4 |
University | 1 |
Source of financial support | |
Woman’s family | 4 |
Husband and woman’s family | 1 |
In paid employment | |
Yes | 0 |
No | 5 |
Polygamous marriage | |
Yes | 4 |
No | 1 |
Others living in husband’s home | |
Yes | 3 |
No | 2 |
If yes, who | |
Husband’s family | 2 |
Second wife of husband | 1 |
Professionals | N = 13 |
Clinic 1 (Area C) | 5 |
Clinic 2 (Area B) | 4 |
Directorate based | 2 |
Trainers | 2 |
Age range | 38 to 55 years |
Sex | |
Female | 9 |
Male | 4 |
Job title | |
Nurse | 1 |
Nurse (Head nurse at clinic) | 1 |
Midwife | 1 |
Clinic case manager | 2 |
GBV focal point (Directorate) | 2 |
General practitioner (Head of clinic) | 2 |
Family medicine doctor | 1 |
Gynaecologist | 1 |
Clinical co-trainer | 1 |
NGO-trainer | 1 |
Data analysis
Results
Normative restructuring
Governing behaviours (of self and others)
It hasn’t helped much [HERA training]. I do feel that my safety is vulnerable due to the lack of laws and legislation which guarantee the safety of healthcare providers. Therefore, there’s no deterrent to stop offenders from taking vengeance on the team and their families. [HP03, GBV Focal Point, Female]
… I’m a woman who protects my home and my husband and my family, my kids … I want someone to advise me to do something that benefits me, but without wrecking my relationship with my husband. Why? Because there are children in the middle. I don’t want a wrecked home … Why should I scatter myself, get a divorce and all that. I don’t want any of that to happen. All I want is to live, like others are living. I have a desire to live for the future. [SW03, Woman, 27 years]
I knew their families are really difficult and would not understand. She might slip one day and say that she went to this doctor and he asked me 1, 2, 3. There’s a great chance they wouldn’t understand, so I was very superficial. Very superficial. I didn’t go deeper. [HP02, Doctor, Male]
Back when we were dealing with the [high risk] case [she] told me that she wouldn’t notify me about any more risky situations which could potentially endanger our lives. Even though police officers might be able to protect us at our workplace, they wouldn’t be able to ensure our safety in the privacy of our homes or on the streets … Never consume yourself in critical cases and always know your limits [HP03, GBV Focal Point, Female]
We were reluctant to go after the young woman to ask her to take a pregnancy test for fear of getting into trouble. Hence eventually we made our minds to rule out that option. That was one of the cases I dealt with and discussed with the training team. We debated how we should have acted during that time, what we should have done if the pregnancy test had come back positive … I would have reported the case to the Case Manager. [HP05, Nurse, Female]
The husband is pressured by those around him, his family, or psychologically he is … financially … So you have to diagnose the cause if it’s because of those around him or is financial. If financial, you have to tell the abused woman to have patience on her husband, be more patient … You have to befriend her and tell her how to get close to him in order to win him over … [HP02, Doctor, Male]
P: … We advised her to solve the dispute with him prudently. We advocated for the use of mutual understanding and common sense, in spite of the difficulties.I: … what do you plan to tell her when she comes for follow-up?P: We plan to give her guidance on how to deal with her husband, how to avoid getting hurt by him and where to go if her problems get out of hand. [HP04, Head of Clinic, Nurse, Female]
So, look we solved things, he used to always hit her and even one time she said he tied her up with rope. He came and told me straight up that he treated his wife this way and that way, and [he] used to hit …. So, after getting closer they went back and now things are going well and I followed up with them. We hope everyone will be like that, to respond and get things back to normal. [HP01, Doctor, Male]
It’s been about two months that I don’t go out at all … I’ve only come here to the clinic. I don’t leave the house, I don’t visit my parent’s home. I’m even forbidden from visiting his relatives [SW03, Woman, 27 years]
They sent family men to talk to me, to convince me [to return] because the next week was school. Who is going to take care of them? Who will be with them?... But the men insisted … and I went back … Also there was some kind of pull with the police [woman reported her husband to the police]. Someone from [name of family] works in the police … but he made everything go smoothly with the police and that’s it, when he makes a call to the police they keep quiet. After a week or two nothing happened. The police didn’t do anything. [SW02, Woman, 30 years]
Confidentiality and controls over knowledge
P: The woman … was escorted to the clinic by her father-in-law on her second appointment. He stood guard at the door of the clinic and kept asking why it took her so long to finish. The moral of the story is that battered women don’t have the luxury to leave the house and move around freely.I: How did you respond to the father-in-law in that case?P: We told him that [she was] was filling a medical report and that the delay was due to computers being down. Where in reality, we were trying to hold her off until the psychologist got to the clinic. [HP04, Head Nurse, Female]
I: And you’re allowed to come here, to the clinic?P: Not always, but I always try to come. Even if I have to lie for my benefit or the benefit of others, that’s okay. [SW04, Woman, 29 years]
… one woman she completed the [domestic violence] questionnaire with everything fine [i.e. no disclosure of violence] and then she said “I want to tell” and she started talking … There are these cases where woman do not want people to know about her being tortured at home. [HP06, Family Planning Nurse, Female]
P: The doctor asked that of me [to document the domestic violence].I: And what did you say?P: He told me “whatever you want to agree” because I refused.I: Can you tell me why you refused?P: Because I wanted the whole subject to be private.I: Okay so you feel as soon as it gets written down, it isn’t private anymore?P: Yes, because I worry that it might get to someone. [SW04, Woman, 29 years]
One time she was beaten by her husband so hard, she came to the clinic complaining of pain in the stomach. I examined her and figured out it was abuse and immediately referred her to the hospital. But I am not very sure if this case was documented … She was documented as a pregnancy follow-up, but I’m not sure if she was documented as a case of abuse. If I see signs of abuse on the face or body of the victim, or if she reaches out to me and tells me that she is abused, as a doctor I write what I see. For example, if a patient claimed she was beaten, but I couldn’t see any signs relating to her claim, I document the patient was beaten as she claims. So, I use the word ‘claim’ which I wouldn’t use if I witness evidence of abuse. We only document those who admit that they were abused. I can’t document a case if the victim denies being abused, even if I saw signs of abuse. [HP10, Gynaecologist, Female]
Some [women] would come to the clinic agitated or acting weird, which would raise my suspicion that something wrong was happening. As a male doctor, I couldn’t reach out to them and offer them help directly. Therefore, I used to call the head of the nurses and tell her to speak to this patient in private. In fact, this happened more than once. And you know it is easier for women to open up and speak to another woman, especially in our culture. [HP11, Director of the Clinic, General Practitioner, Male]
Relational restructuring
Improvisation of practice and transformation of roles
I: What about other members of staff? Have the roles become clear to them as well?P: Yes, they have. The training has opened the door for cooperation between the team members. Since the HERA training, we’ve dealt with many domestic violence cases referred to us by doctors at the clinic. [HP04, Head Nurse, Female]
… These days we actually even taught the reception staff, the pharmacists and other health care providers in this clinic of how to identify a potential violence victim and to directly refer the case to us. So now it has become a cooperative work. [HP09, Clinic Case Manager, Female]
P: Before I talked to her, I felt strangled. I felt strangled like something was holding me around my neck. But after a little I started talking to her I was getting worked up. I wanted to cry and scream, and scream and scream [voice gets higher]. It’s not that I needed to talk, I needed to scream.I: How do you feel now after you’ve spoke to … the nurses?P: I feel like I’ve released a bit … my mental state is relieved. [SW02, Woman, 30 years]
… a pregnant woman with a broken leg due to abuse approached me in the clinic. I offered her referral, but she refused because she didn’t want to lose her kids. Most of the women in this society come to me just to speak out and just to feel like someone listens to them. So, we actually reach a dead end in the management process. The solution in my opinion is creating a national system to support abused women along with their children … and I repeat along with their children [HP10, Gynaecologist, Female]
Synergies with capacity and potential
Limited role legitimacy
It’s imperative that we have to cope with increased workloads due to the nature of our job … I have to serve large numbers of patients on a daily basis … The drop in the number of documented cases was attributed to the heavy workloads in the past month. I bet that if we had fewer workloads or experienced people dedicated to handling domestic violence cases, the outcome would be more efficient than its current state. There would be more room for guidance and counselling, activities and lectures … If we hadn’t been swamped with nursing work all the time, we would have divided the duties between the team members and assumed a more active role in combating violence. [HP04, Head Nurse, Female]
Lack of “higher-level” commitment affecting collective motivation
We wanted them to be closer. If there was more interaction with management it would have been better … we were even more enthusiastic than the health directorate itself, than the supervisor, the minister, the manager, and so, it would give me some motivation. But they tell you, “do as you please, if you want to deal with them [domestic violence cases] welcome, if you don’t want to, as you like” … If we have support from the governorate, the Ministry of Health or the associated authorities … [HP01, Doctor, Male].
Some of them used to come in and go out and see some patients and come in again … the trainees were not fully free for the training, some of them … I mean imagine that you are giving a training and every few minutes you are being interrupted by people coming in and people going out... It was not easy. [Trainer 2]
The clinic is a vital primary healthcare unit with a remarkable number of patients attending its outpatient clinics on a daily basis … It was impossible for staff to attend the full sessions because some needed to fulfil duties during the working hours. [HP03, GBV Focal Point, Female]