The life-time prevalence of intimate partner violence against women (IPV)—defined by WHO (World Health Organization) as ‘behaviour within an intimate relationship that causes physical, sexual or psychological harm, including acts of physical aggression, sexual coercion, psychological abuse and controlling behaviours’—ranges from 15% to 71%, with devastating effects on the health and wellbeing of women and children [
1‐
3]. Interventions to prevent IPV, to adequately manage victims of IPV, and to sanction perpetrators need to involve multiple sectors, including legal, social, health institutions, and civil society. Health services can play an important role in the prevention and management of IPV, and there is general consensus on the main actions that the health sector should carry out [
4,
5]. An expert meeting aimed to provide recommendations for the development of WHO guidelines on health sector response on IPV stated that healthcare services should: ask all women attending services regarding experiences of IPV; stay alert to possible signs and symptoms of IPV; provide healthcare assistance and register all cases; assure women that discomfort and health problems could be related to IPV; inform and orient women on resources available in their communities; ensure privacy and confidentiality; encourage and support women, and respect their own decisions; avoid unsympathetic and blaming attitudes; coordinate with other professionals and institutions; and provide evidence on the magnitude and seriousness of IPV through proper registration and reporting of cases [
6].
Innovations, team learning, and health sector response to IPV
Much attention has been given to the diffusion of innovations in healthcare since the publication of Greenhalgh
et al. in 2004 [
8], but little attention has been given to team learning. Numerous studies showed that the extent of adoption of innovations by healthcare teams depends, among other aspects, on the ability of the team to engage in a learning process [
9‐
13]. Team learning is considered as an important factor in adopting the innovation and adapting it to the local context. In this protocol, we conceptualize team learning as an iterative process in which the healthcare team actively adapts and recreates the innovation; ‘a process that includes positive change produced by investment in developing shared insights, knowledge, and skills’ [
10].
Team learning involves individual, team, and contextual factors, as well as factors related with the characteristics of the innovation itself [
9,
10]. Individuals’ characteristics include,
e.g., self-efficacy, competence, skills, motivation, or prior experiences. Organizational characteristics refer to the characteristics of the team,
e.g., uni- or multi-professionalism, team climate, team identification, team management practices, and leadership characteristics. Contextual factors include societal predisposing influences (
e.g., the socio-cultural aspects), and institutional enabling influences (
e.g., resource availability, decision spaces) [
14,
15]. The innovation itself—in terms of perceived benefit, compatibility, complexity, trialability, and observability [
10,
16]—is also a crucial factor. Moreover, team learning may just be one among other responses of teams to innovations. Health providers may decide to adopt and implement the policy, to adapt it to respond better to suit the needs of patients, or to better suit their own interests or to ignore it [
17].
Team learning cannot be explored as a generic entity, but a process highly dependent on the context where it takes place. Regarding IPV, even if research may produce evidence of the beneficial impact on women’s health of the integration of IPV within health services, this knowledge may not be evident for health providers. Integrating IPV within healthcare practices might not be easily compatible with previous practices, in the sense that it involves new skills and procedures (such as empathic interviewing and networking with social services) and may require more time than an ‘ordinary’ medical consultation. Due to the multifaceted nature of IPV, interventions tackling this problem cannot be simple and uniform, but need to involve different sectors. Innovations in IPV management can be tried out by health providers, but lack of self-confidence regarding how to properly address the issue might hinder their willingness to continue using them. Finally, results of the intervention may not be observable, or may not be the ones expected to achieve—e.g., the woman may return to the aggressor. All these factors influence whether PHC teams engage or not in a learning process to adequately manage IPV. Outcomes, in terms of the development of an organizational culture and shared values favorable to IPV management and the actual delivery of IPV management services, will also depend on whether learning processes are generated or not, and on the characteristics of these processes.
When integrating innovations regarding IPV, the way gender is framed has a strong impact on the type and way that IPV management is integrated into health teams and systems [
18]. Gender defined as ‘the structure of social relations that centers on the reproductive arena, and the set of practices (governed by this structure) that bring reproductive distinctions between bodies into social processes’ [
19] is constructed through relationships that take place at the interpersonal level (gender relations), organizational-institutional level (gender regimes), and broader social level (gender orders) [
19,
20]. Gender is constructed through the interaction of these levels and is translated into concrete practices within healthcare teams, such as the way men and women work together, or the way health providers approach women who have suffered from IPV.
Despite the existence of ample literature dealing, on the one hand, with the integration of innovations within health systems and team learning, and, on the other hand, with different aspects of the detection and management of IPV within healthcare facilities, research that explores how health innovations that go beyond biomedical issues—such as IPV management—become integrated into health systems and that focus on healthcare teams’ learning processes is, to our best knowledge, very scarce if not absent.
The policy and interventions to integrate IPV management within the Spanish health system
This study will be conducted in Spain. This country has made remarkable advances in the development of policies against IPV since 1998. ‘The Gender Based Violence Law,’ passed in 2004, represents a progressive and comprehensive development from the two previous action plans (for the 1998 to 2000 and the 2001 to 2004 periods, respectively) [
21,
22]. On the basis of the law, an array of measures for integral protection against IPV have been implemented, including reforms of the judicial system, extensive training, and the implementation of a comprehensive network of services aimed to protect the rights and safety of women suffering from IPV. Preventive measures directed towards challenging gender inequality at the broader social level have also been established. Despite these noteworthy achievements, IPV remains common, and large differences exist between autonomous regions;
e.g., the self-reported one-year-prevalence of IPV ranged from 28.6% in Ceuta and Melilla to 10.7% in Cantabria, Aragon and La Rioja [
23].
There are few published studies exploring IPV and the health service response in Spain. The existing research pointed out that: the prevalence of IPV among women who use primary level healthcare facilities is high; women perceive favorably being questioned regarding IPV by the general practitioner; and health services are usually the first institution that women affected by IPV reach [
24,
25].
The Spanish health system is highly decentralized. Currently, the 17 autonomous regions are in charge of health planning, public health, and management of health services. ‘The Inter-territorial Council of the National Health System’ is the highest authority in decision making regarding health issues in Spain, and representatives from both the national government and the autonomous regions participate in it.
The 1980s health reform and the National Health Law aimed to strengthen primary healthcare. Health delivery was sectorized and in primary healthcare, multidisciplinary work was promoted. However, success of the primary healthcare approach in Spain has been limited, with large variations between autonomous regions. In general, consultation times have decreased, resources remain scarce, bureaucratic ‘red tape’ has not been reduced, and services continue to favour clinical curative activities over promotion and community-based actions [
26‐
28]. This situation constitutes a challenge for the integration of non-biomedical innovations, such as the management of IPV. The current economic crisis and the increasing cost-reduction measures in public services may further decrease the resources devoted to realizing the primary healthcare approach.
The intervention that we aim to evaluate started from the passing of the ‘Gender Based Violence Law in 2004.’ This law, and the most recent ‘Law For Effective Equality Between Women And Men,’ widen and strengthen the role of health services regarding IPV: they are designed to monitor for possible cases of violence, manage them, and engage in a multidisciplinary response coordinating with other institutions and sectors [
21,
29].
In order to implement the Gender-Based Violence Law in the health sector, a ‘National Commission Against Gender-Based Violence’ (NCAGBV) was created within ‘The Inter-territorial Council of the National Health System.’ The Commission is responsible for monitoring gender-based violence as a public health problem and to improve the prevention, detection, and management of IPV among women attending health facilities. While this description may portray a top-down approach, in reality the implementation of the policy has been less vertical. Indeed, the experience of some regions that started addressing IPV within the health system before the national law was passed was incorporated in the new national policies.
In practice, four main actions have been implemented: development of protocols for a health-care reponse to gender-based violence; training of health professionals; development of information systems; and adapting service delivery [
30‐
36].
Regarding the development of protocols, the NCAGBV developed a common protocol for a healthcare response to gender-based violence published in 2007 and currently under revision [
35]. The common protocol helps providers to ensure a proper management of cases of IPV. For proper detection of cases, the protocol encourages general practitioners (GPs) to ask exploratory questions related to IPV during the first consultation. The protocol elaborates on indicators of suspicion of IPV, and provides tips for conducting empathetic interviews; it also explains how to develop a proper assessment of the bio-psycho-social situation of the woman, the type of violence, and the level of risk. The protocol guides the provider through the intervention process, reminding him/her of the relevant matters that should be addressed [
33,
35]. The conflict between the providers’ obligation to report (in Spain reporting IPV is mandatory for health providers) and the need to respect women’s autonomy is mentioned in the protocol. Due to the participation of representatives of the autonomous regions in the NCAGBV, earlier experiences and protocols from the regions have also informed the elaboration of the national protocol.
Regarding training of health professionals, a working group for training and supervising health professionals on IPV has been created within NCAGBV, and each autonomous region has developed ways to support training. A guide with the basic contents that all training processes should include has been published [
36]. Training has targeted providers at the first level and has taken a variety of forms,
i.e., training on empathetic interviewing and screening, sensitizing on gender equality, and trainer improvement programs. Some ongoing impact evaluations show promising results: training improves health staff awareness and self-confidence, and increases the number of cases detected. Training also enhances providers’ knowledge and appreciation of other available resources (social, emergency, legal), and may strengthen coordination between different health services, as well as interdisciplinary coordination [
32‐
34].
Regarding information systems, the NCAGBV has agreed upon 18 common indicators (although recently they were reduced to 11) in order to improve the quality of information gathered regarding IPV. These indicators are used to measure the prevalence of IPV detected within health facilities and allows disaggregation by the type of violence, women’s characteristics, and type of service. They also provide information about the characteristics of the care provided at the health facility, and the prevalence and type of referrals. How these or other indicators are used to monitor and support the work of healthcare teams on IPV management remains less clear [
33,
34].
Regarding service delivery, it is assumed that all the three interventions described above support the improvement of service delivery for IPV. Additionally, many autonomous regions have developed separate multisectorial plans and pathways to support an interdisciplinary response to women suffering from IPV, connecting the health services with other sectors. Some autonomous regions have, for example, included special measures such as the inclusion of IPV management within the essential components of the PHC portfolio, or the implementation of screening for IPV within PHC services or antenatal care services [
30‐
34].
We argue that all these actions had the potential to generate learning processes within primary healthcare teams. However, it can be assumed that not all primary healthcare teams generated the same learning processes, and consequently, they introduced the management of IPV to a different extent or in diverse ways. These differences might be due to regional factors—due to decentralization of healthcare services, differences exist between autonomous regions in terms, e.g., of the development of regional protocols, the way service is delivered, training schemas, and information systems—and factors that pertain to the team itself.
In this paper, we present the protocol of an evaluation of the integration of IPV management within the Spanish health system, focusing on service delivery within primary healthcare facilities. The study aims to ascertain: why, how, and under what circumstances primary healthcare teams engage (if at all) in a learning process to integrate IPV management in their practices; and why, how, and under what circumstances team learning processes lead to the development of organizational culture and values regarding IPV management, and the delivery of IPV management services. The study will take a realist evaluation approach, exploring the mechanisms through which primary healthcare (PHC) teams learn to integrate IPV management.