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

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This is the published version of a paper published in Gaceta Sanitaria.

Citation for the original published paper (version of record):

Goicolea, I., Marchal, B., Hurtig, A-K., Vives-Cases, C., Briones-Vozmediano, E. et al.

(2019)

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

Gaceta Sanitaria, 33(2): 169-176

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

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N.B. When citing this work, cite the original published paper.

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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

aUnitofEpidemiologyandGlobalHealth,DepartmentofPublicHealthandClinicalMedicine,UmeåUniversity,Umeå,Sweden

bPublicHealthResearchGroup,DepartmentofCommunityNursing,PreventiveMedicineandPublicHealthandHistoryofScience,AlicanteUniversity,Alicante,Spain

cDepartmentofPublicHealth,InstituteofTropicalMedicine,Antwerp,Belgium

dCIBERofEpidemiologyandPublicHealth(CIBERESP),Spain

eFacultyofNursingandPhysiotherapy,DepartmentofNursingandPhysiotherapy,UniversityofLleida,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’responsestointi- 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.

¿Porquéciertosequiposdeatenciónprimariadesaludrespondenmejorala violenciadecompa ˜neroíntimo?Unestudiodecasosmúltiples

Palabrasclave:

Violenciadecompa ˜neroíntimo Equiposdeatenciónprimaria Atencióncentradaenlamujer Estudiodecaso

Análisisderedessociales

re s um e n

Objetivo:Analizarcómolascondicionesdelequipoinﬂuyenenlasrespuestasdelos/lasprofesionales sanitariosalaviolenciadecompa ˜neroíntimo.

Método:Serealizóunestudiodecasosmúltiples.Loscasosfueroncuatroequiposdeatenciónprimaria desaludubicadosenunaregióndelsurdeEspa ña.Dosdeellossecalificaroncomo«buenos»yotrosdos como«promedio».Secalificaroncomo«buenos»losdosequiposconpuntuacionesmásaltasenprácticas encuantoaviolenciadecompa ñeroíntimo,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)mantienenunaestruc- turadereunionesregularesenlasqueseabordaeltemadelaviolencia;3)promuevenunbuenambiente detrabajo;y4)desarrollanaccionesconcretasparaofrecerunaatencióncentradaenlasmujeres.

∗ Correspondingauthor:.

E-mailaddress:isabel.goicolea@umu.se(I.Goicolea).

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

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170 I.Goicoleaetal./GacSanit.2019;33(2):169–176 Introduction

Men’sintimatepartnerviolence(IPV)againstwomenisaglobal publichealthproblemthathasdevastatingeffectsonthehealth andwellbeingofwomenandchildren.^1,2

Thehealthsystem,especiallyprimaryhealthcareservices,can playakeyroleinpreventingandrespondingtoIPV,asstatedin theWorldHealthOrganizationguidelines.^1,3,4Theguidelinesgive acentralrole towomen-centredcare intheimplementationof ahealth-careresponse toIPV:theresponse shouldaddressthe diverseneedsthat everyspecific woman might have and con- fidentiality,support and non-judgementalattitudes have tobe ensured.⁴However,theliteratureshowsthatencountersbetween womenexposedtoIPVandhealth-careprovidersarenotalways satisfactory,^5,6and anumberof barriersthat preventindividual healthcareprovidersfromrespondingtoIPVhavebeenpointed out. These include organizational barriers, time constraints, an attitudeofblamingvis-à-viswomenexposedtoIPV,lackoftrain- 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,dependingontheindividualchar- acteristicsoftheprofessionaland/orthespecifichealthcareteam theyvisitorareassignedto.^8,10Individualcharacteristicsofhealth care professionals such as age, gender, training received, and attitudes towardsIPV have been associated withthe type and qualityofresponseprovidedbyhealth-careproviders.^7,9,11,12Pre- vious studies in Spain have pointed out that the combination ofidentifiedthatteam’sself-efficacy,perceivedpreparation and theimplementationofawoman-centredapproachpromotesbet- 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,processesandoutcomesastheyhappenintheirnatu- ralsetting.Oneofthekeyadvantagesofthecasestudydesignis thatitallowsinvestigatinga“phenomenonwithinitsreal-lifecon- text,especiallywhentheboundariesbetweenphenomenonand contextarenotclearlyevident”.¹⁴Thecasestudydesignencour- agestheuseofdifferentsourcesofinformationanddatacollection methods,whichstrengthensaholisticapproach.Forthesereasons, itiswidelyusedinhealthsystemsresearch.¹⁵

Inthecase studydesign, thesiteselection is purposive:the casesshouldenable‘testing’ofthehypothesis.Itisofteninterest- 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),focusingontheitemsthatrefertoprac- ticeissues.MoredetailsoftheSpanishversionofthequestionnaire canbefoundinVivesCasesetal.¹⁶Professionalsworkinginthe twocasesclassifiedas“good”scoredsignificantlyhigherinprac- 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.^17,18TheSNAquestionnaireinvestigatedtherelation- shipbetweentheteammembersinregardtoIPVconsultations.

SNAmeasuresinteractionsbetweenpairsofactorsandusesthese datatomapthestructureofrelationsandcollaborationinawhole network.Ithasbeenusedtomeasurethedegreeofcollaboration andmutualsupportinnetworks.^17–19Inthisstudy,eachmember oftheteam–ournetworkunderstudy–wasaskedtoidentifyevery othermemberwithwhoms/heconsultedwhenfacingacaseofIPV.

Ninety-threeprofessionalsﬁlledintheSNAquestionnaire.

Qualitativedatawerecollectedthroughsemi-structuredindi- vidualinterviewswithGPs,nurses,midwifes,socialworkersand otherhealthcareprofessionalsworkingineachofthePCCs(atotal of44)(Appendix3online).Issuesincludedintheinterviewsguide arefurtherdescribedinAppendix3online.Theinterviewswere madebytwooftheauthors(EB,IG)anddigitallyrecordedafter writtenconsentwasgranted.Thedurationoftheinterviewsranged from15minutestomorethanonehour.Observationswerecon- ductedinwaiting areasandduringconsultationsandmeetings.

Interactionbetweenusersandprofessionalsandbetweentheteam memberswasobservedandreportedinwrittennotes.

Dataanalysis

ResponsestotheSNAquestionnaireweretabulatedandentered inamatrix.ThesoftwareUCINETwasusedinproducingthegraph- ics.Thenumberofrelationaltiesandthedensityofthenetwork foreachcasewerecalculated.Densityindicatesthedegreeofcohe- 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.²¹Thecodingprocesswasdonemanually.First,we readtheinterviewsseveraltimestoidentifyemergingtopicsof interest,whichwereusedaspredefinedcodes.Weidentifiedthe partsofthetranscriptsreferringtothosecodes,whileatthesame timeremainingopentonewemergingcodes.Next,thepreliminary codeswererefined,expandedandfinallyaggregatedtodevelop themes.

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Ethicalconsiderations

EthicalapprovalforthisstudywasgrantedbytheEthicalCom- 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,theteamsdevelopedspacesforpro- motingteamlearningonIPV.Inthesespacesthroughexchangeand support,lessknowledgeablehealthcareprofessionalsgainednew knowledgeonIPV,andtheyfeltmoresecureandsupportedwhen theyhaddoubts(Table2).

TeamlearningonIPVdidnothappenintheothertwocases whereIPVhasneverbeendiscussedduringregularteammeetings (Table2).

Committedsocialworkersinanenablingenvironment

Wefoundthatsocialworkersarekeyprofessionalsfordealing withIPVinallthefourteams.TheSNAgraphsshowthatinLaVir- genandElCampo,andtoalesserextentinMora,thenetworks arecentralizedaroundthesocialworkers.Thehighcentralization scoresinLaVirgen(0.94)andElCampo(0.93)pointoutthekeyrole ofthesocialworkerinsupportingtheresponsetowomenexposed toIPV.Thelowercentralizationscoresintheothertwocasesindi- catethatthemereexistenceofasocialworkerintheteamisnot enoughtopromoteconsultationsonIPV(Table2andFigs.1to4).

Thequalitativeanalysisshowedthatamongteamswithasocial workerwhowasmotivated,interestedandknowledgeableonIPV, itwaseasiertogenerateinterestonIPVamongtheotherprofes- sionals.Thequalitativeanalysisalsopointedoutthateventhemost committedandknowledgeablesocialworkermightnotbeableto enhanceteamworkifs/heistheonlyoneinterestedand/orifs/he ispartofadisorganizedteam,asthesocialworkerfromElCampo explained(Table2).

Explicitstrategiestoimplementawomen-centredapproach

Thetwo “good”teamswere activelyengagedin implement- ingwhattheycalled“thewomenmalaiseapproach”.Thewomen’s malaiseapproachconsidersthatsomaticsymptomswithnoiden- 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).

Thewomenmalaiseapproachhasinﬂuencedhowtheprofes- sionalsapproachtheirwomenpatients:fromagenderperspective, takingaholisticapproach,tryingtoconnectunspeciﬁccomplains withsocial circumstancesand not onlyfocusing onprescribing drugtoaddresssymptoms.Thisapproachalsoinspiredconcrete actionsbeyondtheclinicalsetting,liketheorganizationofthera- peuticwomen’sgroups:groupsofwomenwhogatheredweekly withtrainedprofessionalsfromtheteamtoengageintalktherapy andotheractivities(i.e.therapeuticmassage).Theexistenceofthe

‘womengroup’inLaVirgenandElCampoexpandedtheoptionsof theteammembersbeyondmerelyreferringtothesocialworker andissuinglegalreports.Asaresult,the‘womengroup’madepro- fessionalsfeellessfrustratedastheycouldofferthewomensome valuableextraoptions(Table2).

Theprofessionals’meetingspreviouslydescribedalsoservedas spaces forexchangeand supportprofessionals inimplementing suchapproach.

Discussion

Thisstudyshowsthattheconditionsoftheteamaffecttheway individualhealthcareprovidersrespondtowomenexposedtoIPV.

HealthcareprofessionalsrespondbettertowomenexposedtoIPV whentheyworkinteams:1)thatfacilitatestafftotalkanddis- cussaboutIPVintheirmeetings;2)wheremembersconsulteach otherwhenfacedwithIPVcases;3)withknowledgeableandmoti- vatedsocialworkers;4)withanenablingteamclimate;and5)that implementconcretestrategiesforwomen-centredcare.

SNAstudieshaveshowedthatdensernetworksfavourthediffu- sionofchanges,especiallywhentheadoptionofthenewbehaviour requires social reinforcement.²⁴ This seems to be the case for IPVresponsewithinprimarycareteams,sincewefoundthatin theteamswithdensernetworks,healthcareprofessionalswere respondingbettertowomenexposedtoIPV.However,wehave acknowledgethatnoneofthenetworksshowedaveryhighden- sity,whichmightreﬂectthatIPVisyettobecomeahealthissuein whichhealthcareprofessionalsroutinelyconsultandcollaborate withothers.⁸Itmightalsoreﬂectthatdespitetheexpectationthat Spanishprimarycarecentersworkasmultidisciplinaryteams,this ishinderedbyworkpressureandthelackofconcretestrategiesor guidelinestodoso.^13,25

Teamstructure,processesandclimatehaveanimpactoninter- disciplinary team working; the importance of ensuring regular teammeetingsandtheavailabilityoforganizationalsupporttofos- terinterdisciplinaryteamworkinprimarycarethatemergedfrom thisstudyhasbeenreportedelsewhere,althoughnotinrelation withIPV.^26,27Team-basedresponsestoIPVcontributetohealth careprofessionalsremainingupdatedbyprovidingspacestolearn- ingfromexchangewitheachother,andtosharetheburden,in termsofworkloadbutalsoemotionalpressure.Moreimportantly, theyallowfor amore comprehensiveresponse toIPV inwhich professionalsfromdifferentsectorsand withdifferentexpertise areinvolved.Theimportanceofaninterdisciplinaryresponseto IPVhasalsobeenacknowledgedintheWHOguidelinesandinthe literature.^1,4

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172 I.Goicoleaetal./GacSanit.2019;33(2):169–176

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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”.²⁸Thekeyroleoforganizationalchampi- onsinpromotingchangewithinlocalcontextshasbeenhighlighted intheliterature.^28–30Whilechampionsmayplayanimportantrole attheinceptionstage(asarguablyisthecaseinourstudy),atlatter

stagesthedevelopmentofa“criticalmass”isnecessary.³⁰Inthat sense,thefactthatthenetworkinLaVirgenshowsacertaindegree ofcentralization aroundotheractorsbeyondthesocial worker, mightpointoutamoreadvancedstageintheimplementationofa team-basedresponsetoIPVinthiscenter.

Theresultsofourstudyareinlinewithotherstudiesthathigh- lightthekeyroleoforganizationalfactorsin shapingindividual healthcareproviders’responsestodifferenthealthissues,inthis casetoIPV.Teamsthathaveagoodclimateandhorizontalleader- shipthatallowsfreedomtohealthcareprofessionalstoinnovate stimulateindividualstoadoptinnovations.^29,31

Finally, this study underlines the relevance of a women- centred approach for facilitating health care responses to IPV,

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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.⁴Thisisacriticalissue,sincethe

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 careprofes- sionalstoimprovehowtheyimplementawomen-centredcarein theirconsultations.Second,thewomen’stherapeuticgroupsserve fourgoals.Theyconstituteacomplementarywaytorespondto

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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.^36,37Itisimportanttonotice 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 careprofessionals;someofthequestionsmightnotbeequallyrelevantfor non-physicians.

Conclusions

Teamlevelstrategiesandprocessesinﬂuencehowhealthcare professionalsrespondtowomenexposedtoIPV.Betterindividual readinesstodetectandrespondtoIPVanda morecomprehen- siveresponsetowomenexposedtoIPVareimplementedinteams

which:1)have socialworkersknowledgeableonIPVandmoti- 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

Thecorrespondingauthoronbehalfoftheotherauthorsguar- antee the accuracy, transparency and honestyof the data and

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

SanSebastiánhavebeeninvolvedintheentireproject,havepar- ticipatedin theanalysisof the data,have criticallyrevisedthe successivemanuscripts.Allauthorshaveapprovedtheﬁnalver- sionofthemanuscriptandallagreetobeaccountableforallaspects oftheworkinensuringthatquestionsrelatedtotheaccuracyor integrityofanypartoftheworkareappropriatelyinvestigatedand resolved.

Funding

ThisstudyhasbeenfundedthroughaCOFASgrant(supported byCOFUNDactionwithintheMarieCurieActionPeople,intheSev- 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.Theauthorsareespe- 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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