Why do certain primary health care teams respond better to intimate partner violence than others? A multiple case study

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GacSanit.2019; :169–176

Original

article

Why

do

certain

primary

health

care

teams

respond

better

to

intimate

partner

violence

than

others?

A

multiple

case

study

Isabel

Goicolea

a,b,∗

_,

_Bruno

_Marchal

c

_,

_Anna-Karin

_Hurtig

a

_,

_Carmen

_Vives-Cases

b,d

_,

Erica

Briones-Vozmediano

b,e

_,

_Miguel

_San

_Sebastián

a

a_Unit_of_Epidemiology_and_Global_Health,_Department_of_Public_Health_and_Clinical_Medicine,_Umeå_University,_Umeå,_Sweden

b_Public_Health_Research_Group,_Department_of_Community_Nursing,_Preventive_Medicine_and_Public_Health_and_History_of_Science,_Alicante_University,_Alicante,_Spain c_Department_of_Public_Health,_Institute_of_Tropical_Medicine,_Antwerp,_Belgium

d_CIBER_of_Epidemiology_and_Public_Health_(CIBERESP),_Spain

e_Faculty_of_Nursing_and_{Physiotherapy,}_Department_of_Nursing_and_{Physiotherapy,}_University_of_Lleida,_Lleida,_Spain

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received5June2017 Accepted3October2017 Availableonline9December2017

Keywords:

Intimatepartnerviolence Primaryhealthcareteam Women-centredcare Casestudy

Socialnetworkanalysis

a

b

s

t

r

a

c

t

Objective:Toanalysehowteamlevelconditionsinfluencedhealthcareprofessionals’responsesto inti-matepartnerviolence.

Methods: Weusedamultipleembeddedcasestudy.Thecaseswerefourprimaryhealthcareteams locatedinasouthernregionofSpain;twoofthemconsidered“good”andtwos“average”.Thetwo teamsconsideredgoodhadscoredhighestinpracticeissuesforintimatepartnerviolence,measuredvia aquestionnaire(PREMIS-PhysiciansReadinesstoRespondtoIntimatePartnerViolenceSurvey)applied toprofessionalsworkinginthefourprimaryhealthcareteams.Ineachcasequantitativeandqualitative datawerecollectedusingasocialnetworkquestionnaire,interviewsandobservations.

Results:Thetwo“good”casesshoweddynamicsandstructuresthatpromotedteamworkingandteam learningonintimatepartnerviolence,hadcommittedsocialworkersandanenablingenvironmentfor theirwork,andhadputintopracticeexplicitstrategiestoimplementawomen-centredapproach.

Conclusions:Betterindividualresponsestointimatepartnerviolencewereimplementedintheteams which:1)hadsocialworkerswhowereknowledgeableandmotivatedtoengagewithothers;2)sustained astructureofregularmeetingsduringwhichissuesofviolencewerediscussed;3)encouragedafriendly teamclimate;and4)implementedconcreteactionstowardswomen-centredcare.

¿Por

qué

ciertos

equipos

de

atención

primaria

de

salud

responden

mejor

a

la

violencia

de

compa ˜

nero

íntimo?

Un

estudio

de

casos

múltiples

Palabrasclave:

Violenciadecompa ˜neroíntimo Equiposdeatenciónprimaria Atencióncentradaenlamujer Estudiodecaso

Análisisderedessociales

r

e

s

u

m

e

n

Objetivo:Analizarcómolascondicionesdelequipoinfluyenenlasrespuestasdelos/lasprofesionales sanitariosalaviolenciadecompa ˜neroíntimo.

Método:Serealizóunestudiodecasosmúltiples.Loscasosfueroncuatroequiposdeatenciónprimaria desaludubicadosenunaregióndelsurdeEspa ˜na.Dosdeellossecalificaroncomo«buenos»yotrosdos como«promedio».Secalificaroncomo«buenos»losdosequiposconpuntuacionesmásaltasenprácticas encuantoaviolenciadecompa ˜neroíntimo,medidasatravésdeuncuestionario(PREMIS,cuestionario quemidelacapacidadderespuestadelos/lasmédicos)queseaplicóaprofesionalesdeloscuatroequipos. Encadacasoserecolectarondatoscuantitativosycualitativosmedianteuncuestionarioderedessociales, entrevistasyobservaciones.

Resultados:Losdoscasos«buenos»presentabandinámicasyestructurasquepromovíanelaprendizaje yeltrabajoenequipoeneltemadeviolenciadecompa ˜neroíntimo,contabancontrabajadorassociales comprometidasconeltemayunambientequelespermitíadesarrollarsutrabajo,yhabíanpuestoen prácticademaneraexplícitaestrategiasparaofrecerunaatencióncentradaenlasmujeres.

Conclusiones:Losequiposquerespondieronmejoralaviolenciadeparejafueronaquellosque:1)tienen trabajadorassocialesbieninformadasymotivadasparainvolucraraotros/as;2)mantienenuna estruc-turadereunionesregularesenlasqueseabordaeltemadelaviolencia;3)promuevenunbuenambiente detrabajo;y4)desarrollanaccionesconcretasparaofrecerunaatencióncentradaenlasmujeres.

∗ Correspondingauthor:.

E-mailaddress:[email protected](I.Goicolea).

https://doi.org/10.1016/j.gaceta.2017.10.005

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Introduction

Men’sintimatepartnerviolence(IPV)againstwomenisaglobal

publichealthproblemthathasdevastatingeffectsonthehealth

andwellbeingofwomenandchildren.1,2

Thehealthsystem,especiallyprimaryhealthcareservices,can

playakeyroleinpreventingandrespondingtoIPV,asstatedin

theWorldHealthOrganizationguidelines.1,3,4_The_guidelines_give

acentralrole towomen-centredcare intheimplementationof

ahealth-careresponse toIPV:theresponse shouldaddressthe

diverseneedsthat everyspecific woman might have and

con-fidentiality,support and non-judgementalattitudes have tobe

ensured.4_However,_the_literature_shows_that_encounters_between

womenexposedtoIPVandhealth-careprovidersarenotalways

satisfactory,5,6_and _a_number_of _barriers_that _prevent_individual

healthcareprovidersfromrespondingtoIPVhavebeenpointed

out. These include organizational barriers, time constraints, an

attitudeofblamingvis-à-viswomenexposedtoIPV,lackof

train-ing,and lack of community resourcestoteam up with, tocite

just a few.7–9 _In _addition, _there _are _strong _inequalities _in _the

response that women exposed to IPV receive from the health

careprofessionals theymeet,dependingontheindividual

char-acteristicsoftheprofessionaland/orthespecifichealthcareteam

theyvisitorareassignedto.8,10_Individual_{characteristics}_of_health

care professionals such as age, gender, training received, and

attitudes towardsIPV have been associated withthe type and

qualityofresponseprovidedbyhealth-careproviders.7,9,11,12

Pre-vious studies in Spain have pointed out that the combination

ofidentifiedthatteam’sself-efficacy,perceivedpreparation and

theimplementationofawoman-centredapproachpromotes

bet-terhealth care responsestowomen exposed toIPV.10 _While _a

primary health care approach is perceived as facilitating more

comprehensive responses to intimate partner violence,

exist-ing health system’s structures are considered not conducive.13

Identifyingandunderstandingpromotiveteamlevelfactorsand

dynamics seems essential in order to strengthen interventions

aimedatimplementinghealth-careactionstopreventandmanage

IPV.

Thisstudyanalyseshowteamlevelconditionsandstrategies

influencehealthcareprofessionals’responsestoIPV.

Methods

Settingandcaseselection

Weadoptedamultiple,embeddedcasestudydesign,sincethis

designallowsforanin-depthexplorationoftheinterrelationship

ofcontext,processesandoutcomesastheyhappenintheir

natu-ralsetting.Oneofthekeyadvantagesofthecasestudydesignis

thatitallowsinvestigatinga“phenomenonwithinitsreal-life

con-text,especiallywhentheboundariesbetweenphenomenonand

contextarenotclearlyevident”.14_The_case_study_design

encour-agestheuseofdifferentsourcesofinformationanddatacollection

methods,whichstrengthensaholisticapproach.Forthesereasons,

itiswidelyusedinhealthsystemsresearch.15

Inthecase studydesign, thesiteselection is purposive:the

casesshouldenable‘testing’ofthehypothesis.Itisoften

interest-ingtochoosecontrastivecasesthatpresentdifferencesincontexts,

interventionmodalitiesoroutcomes.Wechosefourprimarycare

centers(PCCs):LaVirgen,ElCampo,MoraandCristina,locatedin

thesouth-easterncoastofSpain.Twoofthecaseswereclassified

as“good”(LaVirgenandElCampo)andtwoas“average”(Mora

andCristina)inrelationtotheirresponsestoIPV.ThesefourPCCs

werefirstsuggestedbythepersonsinchargeforcoordinatingthe

IPVresponsewithinthehealthsystemofthisautonomousregions.

ResponsetoIPVofeachofthePCCswasafterwardsassessedusing

theSpanishversionofthePhysiciansReadinesstoRespondtoIPV

questionnaire(PREMIS),focusingontheitemsthatreferto

prac-ticeissues.MoredetailsoftheSpanishversionofthequestionnaire

canbefoundinVivesCasesetal.16_{Professionals}_working_in_the

twocasesclassifiedas“good”scoredsignificantlyhigherin

prac-ticeissuesthanthetwocasesdefinedas“average”,adjustingfor

age,sex/gender,professionalbackgroundandyearsofexperience

(moredetailsonthesampleandresultscanbefoundinAppendix

1online).

Totalscoresforpracticeissues,aswellasothercharacteristics

ofeachcasecanbefoundinAppendix2online,whilemoredetails

onthemethods fordatacollectionandsample canbefoundin

Appendix3online.

Datacollection

Quantitativeandqualitativedatawerecollectedfromeachcase

betweenJanuaryandSeptember2013byIGandEB(Appendix3

online).

In each case, a social network analysis questionnaire was

administered to all health care professionals who accepted to

participate.17,18_The_SNA_{questionnaire}_investigated_the

relation-shipbetweentheteammembersinregardtoIPVconsultations.

SNAmeasuresinteractionsbetweenpairsofactorsandusesthese

datatomapthestructureofrelationsandcollaborationinawhole

network.Ithasbeenusedtomeasurethedegreeofcollaboration

andmutualsupportinnetworks.17–19_In_this_study,_each_member

oftheteam–ournetworkunderstudy–wasaskedtoidentifyevery

othermemberwithwhoms/heconsultedwhenfacingacaseofIPV.

Ninety-threeprofessionalsfilledintheSNAquestionnaire.

Qualitativedatawerecollectedthroughsemi-structured

indi-vidualinterviewswithGPs,nurses,midwifes,socialworkersand

otherhealthcareprofessionalsworkingineachofthePCCs(atotal

of44)(Appendix3online).Issuesincludedintheinterviewsguide

arefurtherdescribedinAppendix3online.Theinterviewswere

madebytwooftheauthors(EB,IG)anddigitallyrecordedafter

writtenconsentwasgranted.Thedurationoftheinterviewsranged

from15minutestomorethanonehour.Observationswere

con-ductedinwaiting areasandduringconsultationsandmeetings.

Interactionbetweenusersandprofessionalsandbetweentheteam

memberswasobservedandreportedinwrittennotes.

Dataanalysis

ResponsestotheSNAquestionnaireweretabulatedandentered

inamatrix.ThesoftwareUCINETwasusedinproducingthe

graph-ics.Thenumberofrelationaltiesandthedensityofthenetwork

foreachcasewerecalculated.Densityindicatesthedegreeof

cohe-sionofanetworkwithvaluescloserto1showinghighercohesion.

Networkcentralizationwasalsocalculated;theextenttowhicha

networkisdominatedbyasingle(orfew)centralnode,withvalues

rangingfrom0to1.20

Qualitative interviews were transcribed verbatim and

ana-lyzed using thematic analysis, along with notes taken during

observations.21_The_coding_process_was_done_manually._First,_we

readtheinterviewsseveraltimestoidentifyemergingtopicsof

interest,whichwereusedaspredefinedcodes.Weidentifiedthe

partsofthetranscriptsreferringtothosecodes,whileatthesame

timeremainingopentonewemergingcodes.Next,thepreliminary

codeswererefined,expandedandfinallyaggregatedtodevelop

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Ethicalconsiderations

EthicalapprovalforthisstudywasgrantedbytheEthical

Com-mittee of the University of Alicante (Spain). Written informed

consentwassoughtfromalltheparticipantsinthestudy.

Confi-dentialitywasassured,andpseudonymswereusedforthecases.

Results

Dynamicsandstructuresthatpromoteteamworking andteamlearningonIPV

TheresultsoftheSNAshowedthatthenetworksofLaVirgenand

ElCampohadthehighestdensityscores(Table1andFigs.1to4),

namelywhencasesofIPVwereseenbyhealthcareprofessionals

inLaVirgenandElCampo,moreconsultationswithotherhealth

careprofessionalsintheteamtookplacethaninCristinaandMora.

Thequalitative interviewsand observationssupportedthese

findings.EspeciallyinLaVirgen,themottowasthatIPVcareshould

beprovidedinteams(Table2).

InLaVirgenandElCampo,theteamsdevelopedspacesfor

pro-motingteamlearningonIPV.Inthesespacesthroughexchangeand

support,lessknowledgeablehealthcareprofessionalsgainednew

knowledgeonIPV,andtheyfeltmoresecureandsupportedwhen

theyhaddoubts(Table2).

TeamlearningonIPVdidnothappenintheothertwocases

whereIPVhasneverbeendiscussedduringregularteammeetings

(Table2).

Committedsocialworkersinanenablingenvironment

Wefoundthatsocialworkersarekeyprofessionalsfordealing

withIPVinallthefourteams.TheSNAgraphsshowthatinLa

Vir-genandElCampo,andtoalesserextentinMora,thenetworks

arecentralizedaroundthesocialworkers.Thehighcentralization

scoresinLaVirgen(0.94)andElCampo(0.93)pointoutthekeyrole

ofthesocialworkerinsupportingtheresponsetowomenexposed

toIPV.Thelowercentralizationscoresintheothertwocases

indi-catethatthemereexistenceofasocialworkerintheteamisnot

enoughtopromoteconsultationsonIPV(Table2andFigs.1to4).

Thequalitativeanalysisshowedthatamongteamswithasocial

workerwhowasmotivated,interestedandknowledgeableonIPV,

itwaseasiertogenerateinterestonIPVamongtheother

profes-sionals.Thequalitativeanalysisalsopointedoutthateventhemost

committedandknowledgeablesocialworkermightnotbeableto

enhanceteamworkifs/heistheonlyoneinterestedand/orifs/he

ispartofadisorganizedteam,asthesocialworkerfromElCampo

explained(Table2).

Explicitstrategiestoimplementawomen-centredapproach

Thetwo “good”teamswere activelyengagedin

implement-ingwhattheycalled“thewomenmalaiseapproach”.Thewomen’s

malaiseapproachconsidersthatsomaticsymptomswithno

iden-tifiable organic cause are related to contextual,subjective and

sex/gender-relatedfactors,andthatapurelybiomedicalapproach

Table1

Numberofrelationalties,densityandcentralizationofthenetworksineachofthe PHCteams.

Nrelationalties Density Centralization

LaVirgen 100 0,132 0,935

ElCampo 40 0,19 0,9341

Mora 52 0,094 0,514

Cristina 36 0,055 0,46

tohealththereforecannotadequatelyaddresssuchsymptoms.22,23

Theintervieweesconsideredthatthisapproachchangedtheway

theyapproachwomenduringconsultations.Theyconsidereditkey

toimprovedetectionofIPVand,mostimportantly,tocentrethe

responsetoIPVonthewoman(Table2).

Thisisincontrastwiththeothertwocases,wheretheresponse

focusedmore onfillinglegal reports andconvincingwomen to

denouncetheperpetratorthanoncaring forthewomanherself

(Table2).

Thewomenmalaiseapproachhasinfluencedhowthe

profes-sionalsapproachtheirwomenpatients:fromagenderperspective,

takingaholisticapproach,tryingtoconnectunspecificcomplains

withsocial circumstancesand not onlyfocusing onprescribing

drugtoaddresssymptoms.Thisapproachalsoinspiredconcrete

actionsbeyondtheclinicalsetting,liketheorganizationof

thera-peuticwomen’sgroups:groupsofwomenwhogatheredweekly

withtrainedprofessionalsfromtheteamtoengageintalktherapy

andotheractivities(i.e.therapeuticmassage).Theexistenceofthe

‘womengroup’inLaVirgenandElCampoexpandedtheoptionsof

theteammembersbeyondmerelyreferringtothesocialworker

andissuinglegalreports.Asaresult,the‘womengroup’made

pro-fessionalsfeellessfrustratedastheycouldofferthewomensome

valuableextraoptions(Table2).

Theprofessionals’meetingspreviouslydescribedalsoservedas

spaces forexchangeand supportprofessionals inimplementing

suchapproach.

Discussion

Thisstudyshowsthattheconditionsoftheteamaffecttheway

individualhealthcareprovidersrespondtowomenexposedtoIPV.

HealthcareprofessionalsrespondbettertowomenexposedtoIPV

whentheyworkinteams:1)thatfacilitatestafftotalkand

dis-cussaboutIPVintheirmeetings;2)wheremembersconsulteach

otherwhenfacedwithIPVcases;3)withknowledgeableand

moti-vatedsocialworkers;4)withanenablingteamclimate;and5)that

implementconcretestrategiesforwomen-centredcare.

SNAstudieshaveshowedthatdensernetworksfavourthe

diffu-sionofchanges,especiallywhentheadoptionofthenewbehaviour

requires social reinforcement.24 _This _seems _to _be _the _case _for

IPVresponsewithinprimarycareteams,sincewefoundthatin

theteamswithdensernetworks,healthcareprofessionalswere

respondingbettertowomenexposedtoIPV.However,wehave

acknowledgethatnoneofthenetworksshowedaveryhigh

den-sity,whichmightreflectthatIPVisyettobecomeahealthissuein

whichhealthcareprofessionalsroutinelyconsultandcollaborate

withothers.8_It_might_also_reflect_that_despite_the_expectation_that

Spanishprimarycarecentersworkasmultidisciplinaryteams,this

ishinderedbyworkpressureandthelackofconcretestrategiesor

guidelinestodoso.13,25

Teamstructure,processesandclimatehaveanimpacton

inter-disciplinary team working; the importance of ensuring regular

teammeetingsandtheavailabilityoforganizationalsupportto

fos-terinterdisciplinaryteamworkinprimarycarethatemergedfrom

thisstudyhasbeenreportedelsewhere,althoughnotinrelation

withIPV.26,27_Team-based_responses_to_IPV_contribute_to_health

careprofessionalsremainingupdatedbyprovidingspacesto

learn-ingfromexchangewitheachother,andtosharetheburden,in

termsofworkloadbutalsoemotionalpressure.Moreimportantly,

theyallowfor amore comprehensiveresponse toIPV inwhich

professionalsfromdifferentsectorsand withdifferentexpertise

areinvolved.Theimportanceofaninterdisciplinaryresponseto

IPVhasalsobeenacknowledgedintheWHOguidelinesandinthe

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family doctor nurse social worker midwife paediatrician other 16

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12 5 18

Figure1.

12 10

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7 6

1

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family doctor nurse social worker midwife paediatrician

Figure2.

Thisstudyshowsthatsocialworkersplayakeyrolewhenit

comestoIPV.Thisisnotsurprising,giventhattheyarerecognized

astheexpertsonthisandother“social”issueswithinprimarycare

teams,bothbytherestofthehealthcareprovidersaswellasby

policiesandguidelines.Wealsoshowed,however,thathavinga

socialworkerwithintheteamisnotenoughtofosterateam-based

responsetoIPV.Inordertofosterchange,socialworkershaveto

be“champions”,namely“identifiedwiththeideaastheirown,and

withitspromotionasacause,toadegreethatgoesfarbeyondthe

requirementsoftheirjob”.28_The_key_role_of_{organizational}

champi-onsinpromotingchangewithinlocalcontextshasbeenhighlighted

intheliterature.28–30_While_champions_may_play_an_important_role

attheinceptionstage(asarguablyisthecaseinourstudy),atlatter

stagesthedevelopmentofa“criticalmass”isnecessary.30_In_that

sense,thefactthatthenetworkinLaVirgenshowsacertaindegree

ofcentralization aroundotheractorsbeyondthesocial worker,

mightpointoutamoreadvancedstageintheimplementationofa

team-basedresponsetoIPVinthiscenter.

Theresultsofourstudyareinlinewithotherstudiesthat

high-lightthekeyroleoforganizationalfactorsin shapingindividual

healthcareproviders’responsestodifferenthealthissues,inthis

casetoIPV.Teamsthathaveagoodclimateandhorizontal

leader-shipthatallowsfreedomtohealthcareprofessionalstoinnovate

stimulateindividualstoadoptinnovations.29,31

Finally, this study underlines the relevance of a

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Figure3.

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Figure4.

and the importance of developing concrete strategies for the

implementationofsuchapproach.Theliteratureshows thatthe

implementationofwomen-centredcarefordifferenthealthissues

(i.e. childbirth, cardiovascular disease, drug abuse, and

repro-ductive health) improves women’s satisfaction and utilisation

ofservices, andthat it mayimprove certainhealth outcomes

-although there are some contrasting results.32–34 _However, _to

ourknowledge,therearenostudiesthatexploredhowandwhy

women-centredcarecancontributetobetterhealth-careresponses

toIPV.Despiteinclusionofwomen-centredcareasakeystrategy

forrespondingtowomenexposedtoIPVwithinhealthservices

intheWHOguidelines,thereisnoexplicitguidanceinhowsuch

approachcanbeimplemented.4_This_is_a_critical_issue,_since_the

mainbarrierforimplementingwomen-centredapproachesmight

notbethathealthcareprofessionalsdonotconsideritimportant,

but that routine care processes discourage providers to

prac-ticewomen-centredcareconsistently,ashasbeenalsofoundfor

person-centredcare.35

Ourfindingspointouttwoconcreteactionsthatcansupport

healthcareprofessionalstoimplementedwomen-centredcarein

generalandspecificallyfordealingwithwomenexposedtoIPV.

First,meetingstodiscusscasescanserveasspacestolearn,share

and debrief,and help teamsand individual health care

profes-sionalstoimprovehowtheyimplementawomen-centredcarein

theirconsultations.Second,thewomen’stherapeuticgroupsserve

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Table2

Themesandselectedquotations.

Theme Selectedquotations

Dynamicsandstructuresthatpromote teamworkingandteamlearningon IPV

WealwayssaythatanywomanexposedtoIPV,isnottheresponsibilityofoneprovideroftheteam.Sheismypatient,but sheisalsoknownbyhernurse,bythesocialworker...Shewillbeapatientwhoreceivesacoordinatedsupportfromthe team.(Familydoctor1,LaVirgen)

TeammeetingsareopportunitiesthatIalwaysusetotelltheotherprofessionals:“IfyouseeacaseofIPVyoucancomeand talktome,youcanreferthewomantomeorwecanworktogether...”.Icangivesomesuggestionsandwecansharethe burden,theanxiety(Socialworker,ElCampo)

IhavebeenworkinginthisteamsixyearsandIcantellyouthatwehavenevertalkedaboutIPVinanyofourweekly meetings.(Medicalcoordinator,Mora)

Committedsocialworkersinan enablingenvironment

ImyselfamthesamepersoninElCampoandZarzas[thetwohealthcarecenterssheworkswith]...TheteaminEl Campohasatraditionofworkingformaybemorethan20yearswithapsychosocialapproach,asamultidisciplinaryteam, withasocialworker...TheteaminZarzastheyhavehadasocialworkerformaybewhat?sixyears?...Besides,Zarzasis locatedclosetothecapital,andalotofdoctorswhoareabouttoretire,theywanttocomethere...,andtheycomefromthe ‘oldschool’withabiomedicalworkingstyle[...].Theyunderestimatethevalueofpsychosocialapproaches[...]Inaddition, therelationshipsbetweentheprofessionalsarenotthatgood.Themedicalcoordinatorhasfailedtopromoteteamwork.We donothaveteammeetings[inZarzas].(Socialworker,ElCampo).

Explicitstrategiestoimplementa women-centredapproach

[WhenaskedhowdidshedetectIPVcases]Usually,Inoticethatthiswomanstartscomingfrequentlywhensheseldom camepreviously,orthatshestartscomplainingaboutdifferentissues....,whatwecallthemalaisesyndrome...That’show IhavedetectedIPVcases.Imean,therearewomenwhoarealmostimploringyoutoaskthem...(Familydoctor2,ElCampo) Whentheaimandcarefocusesonthewoman,then[...]establishingatrustrelationshipwillbemoreimportantthanany otherissue,moreimportantthanfillingareport,theprotocol,thebruise...Thisapproachwillhelpmetomakeappropriate decisions.(Socialworker,ElCampo)

Weask[aboutIPV]whenweseeinjuries.[...]Butasaroutine,wedon’taskanything.[...]Whenthereisobjective maltreatment,thentherewillbeadenouncement.Sometimes,weinsistthattheyhavetofilladenouncementform immediately(Familydoctor3,Cristina)

Nowthatwehavethewomen’sgroupthereareissuesthatwecanhandlehereinthehealthcarecenter.Inthegroup, womenworkoutissuesthataredifferentfromtheonesthatcanbedealtwithinindividualconsultations.(Familydoctor4, LaVirgen).

women’sneeds,serveaswellasabackupforprofessionalsbeyond

theirconsultations,provide awayof identification,andremind

professionalsof howcareshouldbedeliveredwithintheteam.

Itisencouragingtopointoutthatsomeautonomousregionsare

alreadyimplementingsimilargroupswithinprimaryhealthcare

and/orothersocio-sanitaryservices.36,37_It_is_important_to_notice

thatimplementingwomen-centredcaredemandsprofessionalsto

incorporateagenderperspectivetohealthandhealth-carewhich

isstillfarfrombeingmainstreamedinhealthcaresystems.

Whilethedesignofthestudyallowsustoseethatthereare

connectionsbetweenteamlevelconditionsandprocessesonone

hand,andindividualreadinesstorespondtoIPV,therearesome

limitations.Duetothedesign, wecannotdemonstratea

cause-effectrelationship.Inaddition,wefocushereinteamlevelfactors,

whiletherecouldbecontextualfactorsbeyondtheteamthatcould

haveinfluencedtheresponses.Wecouldonlycarryoutanin-depth

analysisoffourcases.Itwouldhavebeeninterestingtoexplore

morecontrastingcases(i.e.teamsthatwerenotimplementingthe

womenmalaiseapproachbutwherehealthcareprovidersscored

highfor readiness torespond to IPV).We rely on thePREMIS

scoresforpracticestoqualifyhealthcareprofessionals’responses

toIPV;sincethesescoresarecalculatedfromprofessionals’own

selfreporting,itcanbequestionablewhetherthescoresaccurately

reflectthequalityoftheIPVresponse.Inaddition,inthisstudy

thePREMISwasappliednotonlytophysicians−theoriginaltarget

groupofthe instrument− butalsoto otherhealth care

profes-sionals;someofthequestionsmightnotbeequallyrelevantfor

non-physicians.

Conclusions

Teamlevelstrategiesandprocessesinfluencehowhealthcare

professionalsrespondtowomenexposedtoIPV.Betterindividual

readinesstodetectandrespondtoIPVanda more

comprehen-siveresponsetowomenexposedtoIPVareimplementedinteams

which:1)have socialworkersknowledgeableonIPVand

moti-vatedtoengageothers;2)developandsustainastructureofregular

meetingsduringwhichissuesofIPVarediscussed;3)stimulatea

friendlyteamclimate;and4)implementconcreteactionstowards

women-centredcare.

Whatisknownaboutthetopic?

Primaryhealthcare teamscanplayanimportant rolein respondingtowomenexposedtointimate partnerviolence, butthereishugeheterogeneityinregardtohoweachteam andeachprofessionalrespondsandlittleisknownabouthow teamfactorsinfluencesuchresponses.

Whatdoesthisstudyaddtotheliterature?

To respond better to intimate partner violence primary healthcareteamsshould:1)integratesocialworkerswhoare knowledgeableandmotivatedtoengageothers;2)sustaina structureofregularmeetingsduringwhichissuesofviolence arediscussed; 3)stimulate afriendly climateand a leader-shipthatpromotesindividualinnovation;and4)implement concreteactionstowardswomen-centredcare.

Editorincharge

MaríadelMarGarcía-Calvente.

Transparencydeclaration

Thecorrespondingauthoronbehalfoftheotherauthors

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informationcontainedinthestudy,thatnorelevantinformation

hasbeenomittedandthatalldiscrepanciesbetweenauthorshave

beenadequatelyresolvedanddescribed.

Authorshipcontributions

I. Goicolea was the PI in this project, has bene involved

in the entire project, proposed the idea for this manuscript,

organizedthestructureanddevelopedthefirstdraft.E.

Briones-Vozmedianohasbeeninvolvedintheentireproject,participated

indatacollectionandanalysisandhavecriticallyrevised

succes-sivemanuscripts. B. Marchal,C. Vives-Cases, AK Hurtig and M.

SanSebastiánhavebeeninvolvedintheentireproject,have

par-ticipatedin theanalysisof the data,have criticallyrevisedthe

successivemanuscripts.Allauthorshaveapprovedthefinal

ver-sionofthemanuscriptandallagreetobeaccountableforallaspects

oftheworkinensuringthatquestionsrelatedtotheaccuracyor

integrityofanypartoftheworkareappropriatelyinvestigatedand

resolved.

Funding

ThisstudyhasbeenfundedthroughaCOFASgrant(supported

byCOFUNDactionwithintheMarieCurieActionPeople,inthe

Sev-enthFrameworkprogrammeandtheSwedishCouncilforWorking

Life and Social Research/FAS-Forskningsradet för arbetsliv och

socialvetenskap)throughacompetitivecall.Thisworkwaspartly

supportedbytheUmeåCenterforGlobalHealthResearch,funded

byFAS,theSwedishCouncilforWorkingLifeandSocialResearch

(Grantno.2006-1512).

Conflictsofinterest

Theauthorsdeclarethatthereisnoconflictofinterest.Wehave

topointoutthatoneof theauthors(E.Briones-Vozmediano) is

associatededitorinGacetaSanitaria.However,shehasnotbeen

involvedinanyofthestepsoftheeditorialprocessofthisarticle.

Acknowledgements

TheauthorsaregratefultotheObservatoryofWomen’sHealth

oftheSpanishMinistryofHealth,andtotheprofessionalsincharge

ofIPVprogramswithintheregionalhealthsystemforfacilitating

accesstorelevantinformationandcontacts.Theauthorsare

espe-ciallygratefultotheprimaryhealthcareteamsandtothewomen

patientswhoparticipated in thisstudy, whosharedtheirtime,

enthusiasm,experiences andexpertise,and facilitatedaccessto

unpublishedinformation.

AppendixA. Supplementarydata

Supplementarydataassociatedwiththisarticlecanbefound,in

theonlineversion,atdoi:10.1016/j.gaceta.2017.10.005.

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