Primary health care attributes and responses to intimate partner violence in Spain

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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., Mosquera, P., Briones-Vozmediano, E., Otero-García, L., García-Quinto, M. et al.

(2017)

Primary health care attributes and responses to intimate partner violence in Spain.

Gaceta Sanitaria, 31(3): 187-193

https://doi.org/10.1016/j.gaceta.2016.11.012

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Original article

Primary health care attributes and responses to intimate partner violence in Spain

Isabel Goicolea

^a^,^b^,∗

, Paola Mosquera

^a

, Erica Briones-Vozmediano

^b^,^c

, Laura Otero-García

^d^,^e

, Marta García-Quinto

^b,f

, Carmen Vives-Cases

^b,e,f

aDepartmentofClinicalMedicineandPublicHealth,UnitofEpidemiologyandGlobalHealth,UmeåUniversity,Umeå,Sweden

bGrupodeInvestigacióndeSaludPública,UniversidaddeAlicante,Alicante,Spain

cDepartamentodeEnfermeríayFisioterapia,FacultaddeEnfermeríayFisioterapia,UniversityofLleida,Lleida,Spain

dNursingSection,FacultyofMedicine,UniversidadAutónomadeMadrid,Madrid,Spain

eCIBERdeEpidemiologíaySaludPública(CIBERESP),Spain

fDepartamentodeEnfermeríaComunitaria,MedicinaPreventivaySaludPúblicaeHistoriadelaCiencia,UniversidaddeAlicante,Alicante,Spain

a r t i c l e i n f o

Articlehistory:

Received25August2016 Accepted3November2016 Availableonline20February2017

Keywords:

Primaryhealthcare Intimatepartnerviolence Qualitativecontentanalysis Person-centredcare

a b s t r a c t

Objective:Thisstudyprovidesanoverviewoftheperceptionsofprimarycareprofessionalsonhowthe currentprimaryhealthcare(PHC)attributesinSpaincouldinﬂuencehealth-relatedresponsestointimate partnerviolence(IPV).

Methods:Aqualitativestudywasconductedusingsemi-structuredinterviewswith160healthprofes- sionalsworkingin16PHCcentresinSpain.Datawereanalysedusingaqualitativecontentanalysis.

Results:Fourcategoriesemergedfromtheinterviewanalysis:thosecommittedtothePHCapproach,but withdifﬁcultiesimplementingit;communityworkrelyingonvoluntarism;multidisciplinaryteamwork orprofessionalswhoworktogether?;andcontinuityofcarehinderedbyheavyworkload.Participants feltthatperson-centredcareaswellasotherattributesofthePHCapproachfacilitateddetectingIPVand abetterresponsetotheproblem.However,theyalsopointedoutthatthecurrentmanagementofthe healthsystem(workload,weaksupervisionandlittlefeedback,misdistributionofhumanandmaterial resources,etc.)doesnotfacilitatethesustainabilityofsuchanapproach.

Conclusion: ThereisagapbetweenthetheoreticalattributesofPHCandthe“reality”ofhowthese attributesaremanagedineverydaywork,andhowthisinﬂuencesIPVcare.

Atributosdeatenciónprimariayrespuestasalaviolencia decompa ˜neroíntimoenEspa ˜na

Palabrasclave:

Atenciónprimariadesalud Violenciadecompa ˜neroíntimo Análisisdecontenidocualitativo Atencióncentradaenlapersona

re s um e n

Objetivo:Esteestudiopresentalaspercepcionesdeprofesionalesdeatenciónprimariasobrecómolos atributosdelaatenciónprimariaenEspa ñapuedeninfluenciarlasrespuestassanitariasalaviolenciadel compa ñeroíntimo(VCI).

Métodos:Estudiocualitativoconentrevistassemiestructuradascon160profesionalessanitariosde16 centrosdeatenciónprimariaenEspa ˜na.Losdatosseanalizaronconelenfoquedeanálisisdecontenido.

Resultados:Delanálisisdelasentrevistasemergieroncuatrocategorías:Implicados/asconelenfoquede primaria,peroenfrentandodiﬁcultadesparaimplementarlo;Eltrabajocomunitariodependedelvolun- tarismo;¿Trabajomultidisciplinariooprofesionalesquetrabajanjuntos?;yContinuidadamenazadapor lasobrecargadetrabajo.Losparticipantesconsideraronquelaatencióncentradaenlapersonayotros atributosdelenfoquedeatenciónprimariafacilitabanladeteccióndeVCIyunamejorrespuestaaeste problema.Sinembargo,tambiénreconocieronquelaformaenquesegestionanlosserviciossanitarios (sobrecargadetrabajo,débilsupervisiónyescasofeed-back,distribucióndelosrecursoshumanosy materiales,etc.)nofacilitalasostenibilidaddeesteenfoque.

Conclusión:Existeunabrechaentrelosatributosteóricosdelaatenciónprimariayla«realidad»decómo estosatributossegestionanenlaactividadprofesionaldeldíaadíaydequémaneraestainﬂuyeenla atenciónalaVCI.

∗ Correspondingauthor.

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

http://dx.doi.org/10.1016/j.gaceta.2016.11.012

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188 I.Goicoleaetal./GacSanit.2017;31(3):187–193 Introduction

Men’sintimatepartnerviolence(IPV)againstwomen,isaglobal publichealthproblemandhasdevastatingeffectsonthehealth andwellbeingofwomenandchildren.^1–3Healthcareservices,and especiallyprimaryhealthcarefacilities,canplayakeyroleinalle- viatingtheeffects of IPV,sincetheyare thegatekeepersofthe healthsystemandthereforethepublicinstitutionsmostfrequently accessedbywomenexposedtoIPV,evenifnotallofthemwill disclosethissituation.^1,4–7InthisstudyIPVwasdeﬁnedas“any behaviourwithinanintimaterelationshipthatcausesphysical,sex- ualorpsychologicalharm,includingactsofphysicalaggression, sexualcoercion,psychologicalabuseandcontrollingbehaviours”,³ anditwasexplicitlystatedthatthefocuswasonIPVexertedby menagainstwomen.

When it comes to implementing promotive and preven- tive interventions against complex problems that transcend the traditional responsibilities of the health system, a primaryhealthcare(PHC)approachcharacterizedbytheattributes of person/family-centred, longitudinal, comprehensive, coordi- natedand community-oriented care, is considered to be more effective.^8–10TheattributesofPHCinitiallyproposedbyBarbara Starﬁeldasasetofdimensionstomeasureadequacyoftheprimary careorganizationanditscharacteristicsforservicedelivery,have beenextensivelydescribedaspositivelyassociatedtosuccessful provisionofpreventiveservices.^10,11Undertheseattributes,mul- tidisciplinaryteamsworkinginPHCactasakeyinterfacelinking ambulatorycarewithhospitalandspecialtyservices,andindivid- ualcarewithothercommunity-socialservices.Somestudiespoint outthatthesefeaturesofPHCcouldpositivelycontributetothe implementationofcomprehensiveresponsestoIPV.^12–14

Since the early 80’s when the health care system in Spain underwenta majortransformation, health deliveryhasbecome sectorizedandfocushasbeenplacedonﬁrst-linehealthcarefacili- ties−calledprimaryhealthcarecentres(PHCC)−wherethehealth care workforce is organized around multidisciplinary teams.¹⁵ TheSpanishPHCChavebeendevelopingandexpanding,showing improvedintegrationofservices,goodcoordinationofcare,andan appropriatefamily-orientationwithintheservices.In regardsto thehealthcareresponsetoIPVinSpain,theactionshaveincluded:

training of health care professionals, developing protocols, and establishingmonitoringsystems.

Asof2015,thereare13,187PHCCinSpain,andthehealthsys- temhasperformedwellininternationalcomparisons.^16–19Primary carescoresforSpainareamongthehighestinEuropeintermsof governance,access,continuityandstructuralaspects,mediumin termsofcoordinationandcomprehensivenessandlowerinterms ofefﬁciency.¹⁹Thecurrentﬁnancialcrisishasledtoausteritymeas- ureswithin the Spanishhealth care system, including reduced publicspending,salaryreductionsandreducedservicesforcertain groupslikeundocumentedmigrants.16,18,20–22Thissituationcon- stitutesachallengeforeffectivelydealingwithhealthproblemsin general,²⁰andIPVinparticular.

Thisstudyaimstoprovideasnapshotofthedifferentpercep- tionsofprofessionalsworkinginﬁrst-linehealthfacilitiesonhow thecurrent operationalization of PHCattributes in Spaincould inﬂuencetheresponsestoIPV.

Methods

Participantsanddatacollection

Forthisqualitativestudy,weconductedsemi-structuredindi- vidualinterviews with160 health professionals workingin 16 PHCCs,located in fourdifferentregions. Semi-structured inter- viewsallowtodirecttheissuestobecovered,whileatthesame

time is ﬂexible enoughto incorporatenew emerging issues. It wasalsochosentoenhancehomogeneityofdatacollection,since fourinterviewerswereinvolvedinthisprocess.Professionalback- groundsvaried(Tables1–3).Thedurationoftheinterviewsranged from15minutestomorethanonehour.

FouroftheauthorsconductedtheinterviewsinSpanishfrom January2013untilMarch2014,whichweredigitallyrecordedand verbatimtranscribed.Theaspectsexploredincludedperceptions onthePHCteam’sresponsetoIPV,howIPVhadbeenintegratedin teamwork,individualdifferencesandinvolvement,andrelation- shipswithintheteam.

Thisstudy waspartof a largerevaluation projectexploring how todevelop a health care response to IPVwithin 16 PHCC teamslocatedinfourdifferentregionsinSpain.¹⁴ IneachPHCC weinvitedtoparticipateintheinterviewsprofessionalsfromdif- ferentbackgroundsinordertohaveabroaderperspective.During theinterviewstherelevanceofthePHCapproachforimplemen- tingahealth-careresponsetoIPVemergedstrongly;wetherefore decidedtoexplorethisissuefurtherinthepresentstudy,following anemergentdesign.²³

Dataanalysis

Forthisstudy,alltheoriginaltranscriptionsinSpanishwere analyzedusingqualitativecontentanalysis,²⁴focusingonthecon- nections(anddisconnections)betweentheimplementationofa PHCapproachandthehealth-careresponsetoIPV.Afterreading theinterviewtranscriptsseveraltimes,meaningunitsthatreferred toPHCapproachandIPVresponsewereidentiﬁed,andcodeswere developed.Codesweregroupedtogethertobuildcategoriesand subcategories,thatreﬂectedthemanifestcontentofthetext.

Ethical approval for this study was granted by the Ethical CommitteeoftheUniversityofAlicante(Spain).Thestudywaspre- sentedtothehealthteamsparticipating.Writteninformedconsent wassoughtfromalloftheparticipantsinthestudy.

Results

Fromtheanalysisoftheinterviewsfourcategoriesemerged:

CommittedtothePHCapproachbutfacingdifﬁcultiestoimple- mentit,Communityworkrelyingonvoluntarism,Multidisciplinary teamwork,andContinuityofcarehinderedbyheavyworkload.

Table4displaysthecategories,subcategoriesandselectedcodes, whileTable5displaysselectedquotationsforeachcategory.

CommittedtothePHCapproachbutfacingdifﬁculties toimplementit

Theparticipantsinthisstudywereconvincedoftheimportance ofimplementing a PHCapproach ingeneraland, speciﬁcallyin regardstoIPV.Participantsconsideredthatthepatient/personwas atthecoreofthePHCapproach.Thisimpliedthathealthprofes- sionalsshouldnotonly‘ﬁx’thehealthproblemthatbroughteach patienttothehealthcentrebutalsoexplorethepsychologicaland emotionalspheresandthesocialcontext,inordertobestrespond toher/hishealthneeds. Theyconsideredthatsuchanapproach facilitatedthedetectionof IPVand promoteda betterresponse (Table5).

However, participants complained that health professionals receivedmoretraininginabiomedicalapproachandfarlesstrain- ingon theprinciplesand attributes of thePHCapproach. As a consequence,healthprofessionalsfelttheywerelesspreparedto respondtohealthproblemswithastrongsocialand/oremotional component,suchasIPV(Table5).

DespitepoliciesandprogramsthatpromotePHC,participants feltthatalotofdemandswereputonthemwhiletheworking

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Table1

Numberandmaincharacteristicsofinterviewedprimaryhealthcareprofessionals.Spain,2013.

Region Healthcentre Totalparticipants Women/Men Familydoctors Nurses Midwifes Paediatricians Socialworkers Other

Region1 A 15 11/4 4 7 1 1 1 1

B 11 9/2 4 3 1 1 1 1

C 10 6/4 3 4 1 1 1

D 8 4/4 3 3 1 1

Region2 E 9 7/2 4 2 1 1 1

F 8 5/3 2 2 1 1 1 1

G 9 6/3 2 3 1 1 1 1

H 5 5/0 2 1 1 1

Region3 I 12 9/3 5 4 1 1 1

J 15 10/5 7 3 1 1 1 2

K 10 7/3 5 2 1 1 1

L 6 4/2 5 0 0 0 1 0

Region4 M 9 8/1 3 3 1 1 1

N 11 8/3 3 3 1 3 1

O 12 9/3 3 3 1 2 1 2

P 10 6/4 3 3 1 2 1

Total 160 114/46 56 47 14 19 15 9

Table2

Selectedcharacteristicsofthestudiedautonomousregions.Spain.

Region1 Region2 Region3 Region4

Extensionsquarekilometres(2013) <20000 50000-100000 20000-50000 <20000

Population(2013) <1000000 2000000-3000000 5000000-6

000000

1000000-2000000

Brutinternalproductpercapita(2013) >20000 >20000 <20000 <20000

NumberofPHCCs(2013) <100 >200 >200 <100

LifetimeprevalenceofIPV(SurveyofwomenattendingPHCC2011). 18% 20% 21.4% 29%

GenderbasedviolencedetectionratewithinPHCC(cases/100000women)(2012) 59.8 54.2 23.5 28.1 IPV:intimatepartnerviolence;PHCC:primaryhealthcarecentres.

Table3

Selectedcharacteristicsofthestudiedprimaryhealthcarecentresteams.Spain,2013.

Region Healthcenter No.healthprofessionals Location

Region1 A 38 Urban,capital

B 24 Urban,nocapital

C 16 Rural

D 13 Rural

Region2 E 22 Urban,capital

F 26 Urban,capital

G 23 Rural

H 25 Urban,capital

Region3 I 35 Urban,capital

J 21 Rural

K 33 Rural

L 32 Urban,capital

Region4 M 33 Urban,capital

N 29 Smalltowninrural-agriculturalarea

O 25 Smalltowninrural-artisans/agriculturalarea

P 28 Urban-regionalcapital

Table4

Categories,subcategoriesandselectedcodesemergingfromtheanalysisoftheinterviews.Spain.

Category Subcategories Selectedcodes

CommittedtothePHCapproachbutfacing difﬁcultiestoimplementit

•ConvincedoftherelevanceofaPHCapproach

•PHCapproachnotsystemizedinthetrainingof healthprofessionals

•Forgottenbythemanagers

•Multicausalityofillnesses

•Educatedinabiologicistmodel

•Managerialdemandswithoutsupport Communityworkrelyingonvoluntarism •Interestandcommitmentwithcommunitywork

•Littleroomforhealthpromotionandcommunity work

•Motivatedtodocommunitywork

•Therapeuticgroupsareeffective

•Communityworknotsustainable

•Communityworkbasedonvoluntarism Multidisciplinaryteamworkorprofessionals

whoworktogether?

•Multidisciplinaryteamworknotsystemized

•Communicationspontaneouslyimplemented

•Therelevanceofthe‘mini-team’

•Keyroleofsocialworker

•Professionalsworkingunderthesameroof

•Goodinformalcollaboration

•Basictriad:doctor-nurse-socialworker

•Socialworkerknowsbest Continuityofcarehinderedbyheavyworkload •Heavyworkloadhinderstherealizationofa

person-centredcare

•Continuityofcarepromotesperson-centredcare

•Long-termrelationswithpatientsandfamilyfocus mightchallengeIPVresponse

•Hardtodevelopempathywithshortconsultation times

•Longtermrelationshipwithpatients

•Knowsherpatients

•Feartodamageprofessional-patientrelationship PHC:primaryhealthcare.

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190 I.Goicoleaetal./GacSanit.2017;31(3):187–193

Table5

Categoriesandselectedquotations.

Category Selectedquotations

CommittedtothePHCapproachbutfacing difﬁcultiestoimplementit

Everypersonisbio-psycho-social,youcannotaddressanyofthethreeaspectsisolatedfromtheothers,andeven lesswhenitcomestoIPV.[...]WewhoworkinPHCCswemainlyseethepsychosocialconsequencesonIPVinour patients(Familydoctor1,PHCCP,Region4)

Thoseissues,includingthebiopsychosocialapproach,arestillnotpartofthecurriculumofmedicalstudies(Family doctor2,PHCCE,Region2)

IthinkthatweapplyanapproachthatisascomprehensiveandasalignedwiththePHCapproachasthepolitical andeconomicsituationallowusto(Midwife,PHCCA,Region1)

Communityworkrelyingonvoluntarism InSpainit’sverydifficulttodobothclinicalandcommunityworkinaPHCC...,it’sbecauseofthewayPHCis organized-curativeworkpresidesoverprevention[...]Theself-helpgroupsforwomenthatwerunareagreat resourceforwomenexposedtoIPV,...that’sthetypeofworkweshouldbedoinginPHCCs,butnowadaysit’svery hardtodo...NowadaysifIwanttoengageinsuchactivities,firstIhavetofinishmy‘workinghours’,andonlythen Icanengagein‘otherbusiness...Workinglikethatpeoplegetworn-out(Familydoctor3,PHCCC,Region1) Multidisciplinaryteamworkorprofessionals

whoworktogether?

WhenIarrivedtothishealthcenteroneofthedoctorstoldme:Youarewelcome,evenifIdon’tgetaclueofwhat doyouhavetodohere(SocialWorker,PHHCC,Region1)

IhavenoideahowmycolleaguesaredealingwithIPV,Iguesstheymightbedoingwell[...]Thiscentreisfullof goodpeople,committedandveryprofessional,butwedonotworkasateam(Familydoctor4,PHCCF,Region2) CasesofIPVthatIamawareof,theyhavebeendealincoordinationbetweennurseanddoctor;thereisa relationship,weworkveryclosetoeachother,wecommunicateeasily,(Nurse1,PHCCO,Region4)

Thesocialworkeristheonetowhomwecomewithallourquestions(inregardstoIPV)(Nurse2,PHCCI,Region3).

Weshouldneverreferwomentogetthemlostinthesystem(Socialworker,PHCCI,Region3)

Continuityofcarehinderedbyheavyworkload IfIhaveafullagenda,thatdayIwillnotask[aboutIPV],Iamfullyawareofthis...ThatdayIwillnotask,because thewaitingroomisfull[...].ThenumberofpatientsIhavetoseeinﬂuenceswhetherIaskornot(Nurse3,PHCCH, Region)

[IPV]iseasiertoaddressinPHCCsduetotheclosenesswegetwiththepatient[...]thedoctorgetsaccesstothe woman’sclinicalrecord,butshealsoknowsherfamily,hersituation;that’swhyIthinkit’seasiertodetectand respondtoIPVinPHCCs.Atthehospitallevel,theymightonlyseephysicalinjuries(Midwife1,PHCCF,Region2) WhenIhaveacaseofIPVImakeanotherappointmentforanotherday[...]Timeconstrainsapplyonadailybasis, butinthelongrunifIwanttogetindepth,Icandoit;Ihave1500patientsinmypractices,andinthelongrunI knowallofthem(Familydoctor6,PHCCA,Region1)

environment didnot supporttheirefforts toimplement a PHC approachintheireverydaypractice(Table5).

Facedwithsuchadiscouragingenvironment,someofthepartic- ipantsfeltdispiritedwhileothersengagedininitiativestoimprove thePHCcompetenciesofhealthprofessionals,throughengagingin medicalassociations,trainingmedicalresidents,etc.

Communityworkrelyingonvoluntarism

FiveofthevisitedPHCCwereimplementinghealthpromotion orcommunity-basedinitiativesrelatedwithIPVprevention,such asself-helpgroupswithwomen.Inallofthosecentres,themedical coordinatorfacilitated suchactivities,althoughsometimescon- ﬂictsemergedwhencolleagueshadto‘cover’forprofessionalswho wereengagedincommunity/healthpromotionwork.

Participants acknowledgedthat such initiativeswere imple- mented and sustained through the personal interest and commitmentof agroupofprofessionals, usuallyheadedbythe socialworker.Ifsuchprofessionalsgottiredormovedtoanother centre,thentheinitiativesgotdiscontinued.Theyidentiﬁedanum- berofbarriersforsustainingthecommunity-orientationofthePHC approach:workload,scarceandunequalsupportfromthemanage- riallevel,theconsiderationofcommunityworkasoptional,thefact thathealthcareprofessionalsmightneitherbewellpreparednor accustomedtoengageinsuchactivities(Table5).

Multidisciplinaryteamworkorprofessionalswhoworktogether?

Theinterviewed health professionals consideredthat health policiesandprogramsinSpainputemphasisontheimportanceof teamworkandmultidisciplinarity.However,theyconsideredthat therewasagapbetweensuchpoliciesandtheirimplementation, sincestructurestopromoteandfacilitateworkasmultidisciplinary teamshave failedtobesustainedaspartoftheroutinesofthe healthprofessionals.Professionals’hierarchieswerealsoconsid- eredabarriertoworkasamultidisciplinaryteam.Theexpertiseof

certainprofessionalslikephysiotherapists,midwivesandnurses wasnotasvaluedasthatofmedicaldoctors.Incertainhealthcen- ters,socialworkerscomplainedaboutthescarceknowledgeand recognitionoftheirexpertise(Table5).

Continuousreferencesweremadetoaveryindividualisticstyle ofwork,inwhichitwasdifﬁcultforprofessionalstoknowhow theircolleagueswererespondingtoIPVortootherhealthproblems (Table5).

Duetothelackofguidelinesstructuringtheworkofmultidis- ciplinaryteams,professionalspointedoutthatteamworkhadto relyonthegoodcommunicationandrelationshipsbetweenthecol- leaguesataninformallevel.Communicationduringcoffee-breaks, knockingonthedoorofa colleaguetodiscussparticularcases, or informal meetingswere opportunitiesto discuss issues that emergedduringconsultations,includingIPVcases.

Thehealthprofessionals participatinginthis studyacknowl- edgedthekeyroleofwhattheycalledthemini-team,namelythe familydoctorandnursewhowereassignedtothesamepatient.

Coordinationwithpaediatriciansormidwifes,wasmoreerraticand stronglydependentonthepersonalinterestofcertainprofession- als.Onthecontrarytheexistenceofasocialworkerwithintheteam wasconsideredasacornerstoneforrespondingtoIPVduetotheir expertiseonthisandotherissuesconsidered‘social’(Table5).

Themostcommittedprofessionalswarnedoftherisksofreduc- ing multidisciplinary work to “referring” patients as a way to gettingridofthem.Theyﬁrmlysupportedthatonceawomandis- closedIPVwithaprofessional,sheorheshouldstaywithher,and referonlywhenthewomanwantedto(Table5).

Continuityofcarehinderedbyheavyworkload

Participantscomplainedabouthowworkloadandshortconsul- tationtimeshinderedtheimplementationofperson-centredcare aswellasthreatenedthecoordinationofservices.Theyfeltthat thiswasespeciallydeleteriousforthedetectionandresponseto IPV.

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Despitetheworkoverload,participantsacknowledgedthatthe wayPHCcentresworkinSpainfacilitatedtheestablishmentofrela- tionshipsoftrustbetweenhealthprofessionalsandpatients,and suchrelationshipswereperceivedasenhancingthelikelihoodof detectinganddisclosingIPV.Participantsalsomentionedthatthe shortconsultationtimesweresomehowcompensatedbycontinu- ityovertime.

However,thislong-termrelationshipestablishedwithpatients wasconsideredbysomeparticipantsasanobstacletothedetection ofIPVduetoover-conﬁdenceon‘knowingeverythingabouttheir patients’orfearofbreakingagoodprofessional-patientrelation- shipbybringingupasensitivetopic.ThefamilyfocusofthePHCCs aswellasthefactthatfamiliesareusuallyassignedtothesame healthprofessionalsallowedabroaderknowledgeofthesituation ofeachpatient.However,thischaracteristicbecameachallengein casesofIPV,whenthesamehealthprofessionalwasassignedto boththevictimandtheaggressor.Thissituationbroughtcompli- cationsintermsofsecurity,conﬁdentialityand/ortheemotional burden.

Discussion

Thisstudycapturesbothprofessionals’perceptionsonthecur- rent(weak)presentationofPHCattributesinSpainandtheirviews onhowsuchattributes,whenactuallypresent,canpromoteacom- prehensiveresponsetoIPV.

In linewithourﬁndings, otherstudiesevidence thata PHC approachfacilitatestheintegrationofhealthcareresponsestocom- plexhealthproblems,i.e.mentalhealth.²⁵PreviousstudiesinSpain supporttheimportanceofthePHCapproachasarelevantcondi- tiontriggeringbetterresponsestoIPV.^13,14However,participants alsoacknowledgedthechallengestosustainthePHCapproachin Spainduetotheweaktrainingprovidedbothduringundergrad- uatestudies andin-service. Moreover,theimplementationof a person-centredbio-psycho-socialapproachmightriskfocusingon solutionsattheindividuallevel,whiletherootofmanyhealthprob- lemsingeneralandIPVinparticularliesmainlyatthebroadersocial level.²⁶

Complaintsabouttheeffectofhealthcareausteritymeasures ontheworkloadofprimaryhealthcareteamsinSpainhavebeen reportedinotherstudies.²⁰Thisstudydescribeshowhealthcare professionalsperceivedtheirdeleteriouseffectforthesustaina- bilityofthePHCattributesandforrespondingtoIPV.However,such complainscouldalsorepresentwaystojustifyevadingresponsi- bilities,inanissuethatremainscontroversial.Onecannotforget that thehealth systemreproduces thegenderorder of a given society,stronglyinﬂuencingprofessionals’practices,attitudesand priorities.^27,28

Community-orientationiscommonlyrecognizedasoneofthe mostchallengingattributestoachievewhenimplementingaPHC approachwithinhealthsystems.^8,16PreviousstudiesinSpainshow thatthisattributehasbeennotinfocuswithintheSpanishPHCin general,andevenlessinregardstoIPV.²⁹Lackofsupportfromthe manageriallevelandthefactthatcommunityworkhasnotbeen includedwithintheobjectivesevaluatedannuallyhavebeenmen- tionedashinderingcommunity-orientationofPHCinSpain.^30,31 Thisstudycoincideswiththeseﬁndingsbutalsopointsoutanother key issue: community workin relationwith IPV is considered importantandPHCteamsdoengageinsuchinitiatives,although inavoluntarybasis,verymuchdependingonindividualprofes- sionals’commitment,whichmakesworkhardtosustain.Asthe WHOguidelinespointout,ahealthcareresponseshouldinvolve notonlydetectionandreferral,butalsopreventiveandcommunity work.⁷Suchworkcancontributetoprofessionals’perceivedself- efﬁcacyindealingwithIPV,sincetheymightfeelthattheyhave

‘somethingtooffer’.^13,14Theexistenceofvariouscommunityactiv- itiesandlocalizedinitiativestopromotecommunityworkmight facilitatechangestowardsastrongercommunity-orientation.^32,33 Multidisciplinary team work is important to offer an IPV responsecentredonthediverseneedsofwomenexposedtoIPV^1,7; i.e.,thenurseandmedicaldoctorcandetectandfollowup,the socialworker canworktherapeuticallyand connectthewoman withotherresources,thepaediatriciancanexploretheeffectsof IPVonherchildren.TheorganizationoftheSpanishPHCservices allowspatientstomeetdifferentprofessionalsinthesamefacility;

theintegrationofsocialworkerswithinPHCteamsseemsespe- ciallyrelevantforofferingacomprehensivehealthcareresponse toIPVandforconnectingthePHCCwithotherresources.However, themereexistenceofdifferentprofessionsunderthesameroof doesnotensurethatcasesofIPVreceiveamultidisciplinaryand coordinatedresponse.Inordertodoso,team-supportingstruc- tures should be developed, establishing cleargoals, division of labor, training of team membersin their personal rolesand in teamfunctioning.SuchstructuresappearedtobeweakinSpain, andweretoodependentonprofessionals’voluntarism,whichhin- derstheirsustainabilityandeffectiveness.Areviewoffacilitators andbarrierstointer-professionalcollaborationpointedoutthat perceivedhierarchywasthemainconceptualbarrierhinderingcol- laboration,whichwasalsopointedoutinourstudyandothers.^27,34 Multidisciplinarytraining couldfacilitatechangeonhealth professionals’ perceptions and enhance awareness of each other’s roles.³⁴

Themostcommittedprofessionalsinthisstudyalsohighlighted theimportanceofbuildingandkeepingtrustwithwomenwhodis- closeIPVandthatreferringorconsultationwithotherprofessionals shouldnotbecomeaneasyscape.Buildingtrustisalsomentioned aspartoftheWHOrecommendations.⁷

ThisstudyshowedthatthewayPHCCsareorganizedinSpain allowslongitudinalcontinuityandensurestheestablishmentof longtermrelationshipwithpatientsthat,toacertainextent,com- pensatefortheshort(ening)consultationtimes.Ontheonehand, theﬁndingsfromthisstudycoincidewithotherstudiesthatshow thatbuildingtrustrelationshipsbetweenhealthprofessionalsand womenexposedtoIPViskeyinordertoimproveIPVdetection andresponse.^4,5Ontheotherhand,thisstudyalsopointsoutthat closerelationshipsbetweenprofessionalsandpatientsmightpre- vent detection due toover conﬁdence or fear of damagingthe relationshipfromthepointofviewoftheprofessional.Thefamily- focusedPHCCsinSpainmightenhanceprofessionals’knowledge ofthepatient’ssituationbutalsopossessesgreatchallengestothe implementationofIPVresponses;i.e.safetyforboththeprofes- sionalsandthevictimsmightbeputatrisk.Itisimportanttonote thattheWHOguidelinesfailtoaddressthisaspectthoroughly.⁷

Thisstudywasbasedinaspeciﬁcsetting,Spain,acountrywith adecentralizedanduniversalpublichealthsystem,anextensive networkofPHCCs,andwherehealthpoliciesagainstIPVhaveﬂour- ished.ThesecharacteristicsaresharedbyanumberofWesternEU countries,andthusourresultsmaybetransferabletothem.

Aswehavedescribedbefore,thisresearchwaspartofalarger studyinwhichexploringthelinkagebetweentheattributesofPHC andIPVwasnotthemainfocus;thus,wemayhavefailedtoinquire ingreaterdepthonrelevantissues.However,thecentralroleofthe PHCattributesinshapingPHCteamresponsestoIPV,andthechal- lengestosustainingsuchattributesemergedfromthedata,andthis waswhatmotivatedthisstudy.Wearguethatfollowinganemer- gentdesignaddstothestudy’sdependability,whichcontributesto researchtrustworthiness.²³

Sincetheparticipationwasvoluntaryitislikelythatthesample overrepresentstheperceptionsofthoseprofessionalsmoresen- sitizedwithIPV.Thehigherproportionofwomeninthesample mightreﬂectthisaswell.However,aneffortwasmadetoinvite

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192 I.Goicoleaetal./GacSanit.2017;31(3):187–193

professionalswhoweremoreskepticalwiththetopic,although thiswasnotalwayssuccessful.

Duetothestudydesign wecannot claimthat acausalrela- tionexistsbetweenPHCattributesandIPVresponses.However, weconsiderthatthisstudyisaﬁrststepforimprovingourunder- standingonhowPHCattributescancontributetobetterhealthcare responsestoIPVandthecomplexityoftheirimplementationinthe daytodaypracticesofPHCCteams.

Whatisknownaboutthesubject?

The implementation of primary health care attributes

−person/family-centred,longitudinal,comprehensive,coordi- natedandcommunityoriented−facilitatestheimplementation ofinterventionsagainstcomplexproblems.

Whatdoesthisstudyaddtotheliterature?

Healthcareprofessionalsperceivedthataprimaryhealth careapproachfacilitatesmorecomprehensiveresponsesto intimatepartnerviolence,butexistinghealthsystem’sstruc- tures were not conducive. In order to implement more comprehensiveandsustainablehealthcareresponsestointi- matepartnerviolence,healthsystemsshouldstrengthenthe realizationoftheprimaryhealthcareattributes.

Editorincharge

MaríaTeresaRuizCantero.

Transparencydeclaration

Thecorrespondingauthoronbehalfoftheotherauthorsguar- antee theaccuracy, transparency and honesty of thedata and informationcontainedinthestudy,thatnorelevantinformation hasbeenomittedandthatalldiscrepanciesbetweenauthorshave beenadequatelyresolvedanddescribed.

Authorshipcontributions

I.GoicoleawasthePIinthisproject,proposedtheideaforthis manuscript,organizedthestructureanddevelopedtheﬁrstdraft.

E.Briones-Vozmediano,L.Otero-GarciaandM.Garciahavebeen involvedintheentireproject,participatedindatacollectionand analysisandhavecriticallyrevisedsuccessivemanuscripts.P.Mos- queraandC.Vives-Caseshavebeeninvolvedintheentireproject, haveparticipatedintheanalysisofthedatahavecriticallyrevised thesuccessivemanuscripts.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.Oneofthe authors(E.Briones-Vozmediano)belongstotheGacetaSanitaria editorialcommittee,butwasnotinvolvedintheeditorialprocess ofthemanuscript.

Acknowledgements

TheauthorsaregratefultotheObservatoryofWomen’sHealth oftheSpanishMinistryofHealth,andtotheprofessionalsincharge ofIPVprogramswithintheregionalhealthsystemforfacilitating accesstorelevantinformationandcontacts.Theauthorsareespe- ciallygratefultotheprimaryhealthcareteamsandtothewomen patientswhoparticipated in thisstudy, whosharedtheirtime, enthusiasm,experiences andexpertise,and facilitatedaccessto unpublishedinformation.

References

1.Garcia-MorenoC,HegartyK,d’OliveiraAF,etal.Thehealth-systemsresponse toviolenceagainstwomen.Lancet.2015;385:1567–79.

2.Vives-CasesC,Ruiz-CanteroMT,Escriba-AguirV,etal.Theeffectofintimate partnerviolenceandotherformsofviolenceagainstwomenonhealth.JPublic Health.2011;33:15–21.

3.WorldHealthOrganization.Globalandregionalestimatesofviolenceagainst women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva: World Health Organization; 2013.

(Accessed26/10/2016).Availableat:http://www.who.int/reproductivehealth/

publications/violence/9789241564625/en/

4.BeynonCE, GutmanisIA,Tutty LM,etal.Whyphysicians andnursesask (ordon’t)aboutpartnerviolence:aqualitativeanalysis.BMCPublicHealth.

2012;12:473. (Accessed 26/10/2016). Available at: http://bmcpublichealth.

biomedcentral.com/articles/10.1186/1471-2458-12-473

5.ChangJC,ClussPA,RanieriL,etal.Healthcareinterventionsforintimatepartner violence:whatwomenwant.Women’sHealthIssues.2005;15:21–30.

6.MonteroI,Ruiz-PérezI,Martín-BaenaD,etal.Violenceagainstwomenfrom differentrelationshipcontextsandhealthcareutilizationinSpain.Women’s HealthIssues.2011;21:400–6.

7.WorldHealthOrganization:Respondingtointimatepartnerviolenceandsex- ualviolence againstwomen.WHO clinicaland policyguidelines. Geneva:

World Health Organization. 2013. (Accessed 26/10/2016). Available at:

http://apps.who.int/rhl/guidelines/9789241548595/en/

8.MacinkoJ,AlmeidaC,deSáPK.Arapidassessmentmethodologyfortheevalua- tionofprimarycareorganizationandperformanceinBrazil.HealthPolicyPlan.

2007;22:167–77.

9.ShiL.Theimpactofprimarycare:afocusedreview.Scientiﬁca.2012;9.(Accessed 26/10/2016). Available at: https://www.hindawi.com/journals/scientiﬁca/

2012/432892/

10.StarﬁeldB,ShiL,MacinkoJ.Contributionofprimarycaretohealthsystemsand health.MilbankQuarterly.2005;83:457–502.

11.StarﬁeldB.Atenciónprimaria.Equilibrioentrenecesidadesdesalud,serviciosy tecnología.Barcelona:Masson;2001.p.518.

12.Briones-Vozmediano E, Maquibar A, Vives-Cases C, et al. Health-sector responsestointimatepartnerviolence:ﬁttingtheresponseintothebiomed- icalhealthsystemoradaptingthesystemtomeettheresponse?JInterpers Violence.2015.Availableat:http://dx.doi.org/10.1177/0886260515619170 13.GoicoleaI,HurtigA-K,SanSebastianM,etal.Developingaprogrammethe-

orytoexplainhowprimaryhealthcareteamslearntorespondtointimate partnerviolence:a realistcase-study.BMC HealthServRes.2015;15:228.

(Accessed26/10/2016).Availableat:http://bmchealthservres.biomedcentral.

com/articles/10.1186/s12913-015-0899-8

14.Goicolea I, Vives-Cases C, Hurtig A-K, et al. Mechanisms that trigger a good health-care response to intimate partner violence in Spain. Com- bining realistevaluationand qualitative comparativeanalysisapproaches.

PLoS one. 2015;10:e0135167 (Accessed 26/10/2016). Available at: http://

bmchealthservres.biomedcentral.com/articles/10.1186/s12913-015-0899-8 15.LeyGeneraldeSanidad.L.N.^◦14/1986(25abril1986).

16.BorkanJ,EatonCB,Novillo-OrtizD,etal.Renewingprimarycare:lessonslearned fromtheSpanishhealthcaresystem.HealthAffairs.2010;29:1432–41.

17.EuropeanObservatoryonHealthSystemsandPolicies:Healthsystemsintran- sition:Spain.Copenhagen:WorldHealthOrganization;2010.

18.GervasJ,PerezFernandezM,SanchezSanchezRJ.[Longitudinality,prestige, goodreputation(socialandprofessional)andgeneral/familymedicine.Clini- calandpublichealthaspects.SESPASReport2012].GacSanit.2012;26(Suppl 1):52–6.

(8)

19.EuropeanObservatoryonHealthSystemsandPolicies:Buildingprimarycarein achangingEurope.Copenhagen:WorldHealthOrganization;2015.

20.Heras-MosteiroJ,Otero-GarcíaL,Sanz-BarberoB,etal.Percepcionesdemédicas ymédicosdeatenciónprimariadeMadridsobrelasmedidasdeajusteenel sistemapúblicodesalud.GacSanit.2016;30:184–90.

21.Legido-QuigleyH,OteroL,laParraD,etal.Willausteritycutsdismantlethe Spanishhealthcaresystem?BMJ.2013;346:f2363.

22.ManuelMartinG.Laatencionprimaria,antesydespuesdelaLeygeneralde Sanidad.En:FADSP,editor.Treintaa ñosdelSistemaSanitarioespa ñol(1981- 2011).Treintaa ñosdelaFederacióndeAsociacionesparalaDefensadela SanidadPública.Madrid:FADSP;2011.p.183–92.

23.LincolnYS,GubaEG.Naturalisticinquiry.London:Sage;1985.p.416.

24.GraneheimUH,LundmanB.Qualitativecontentanalysisinnursingresearch:

concepts,proceduresandmeasurestoachievetrustworthiness.NurseEduc Today.2004;24:105–12.

25.WorldHealthOrganization.Integratingmentalhealthintoprimarycare:aglobal perspective.Geneva:WorldHealthOrganization;2008.

26.Borrell-Carrió F, Suchman AL,Epstein RM.The biopsychosocialmodel 25 years later: principles, practice, and scientiﬁc inquiry. Ann Family Med.

2004;2:576–82.

27.FernándezMorenoSY.Laviolenciadegéneroenlasprácticasinstitucionalesde salud:afectacionesdelderechoalasaludyalascondicionesdetrabajoensalud.

RevistaGerencialPolíticasSalud.2007;6:52–76.

28.Connell RW. Gender and power: society,the person and sexual politics.

Cambridge:JohnWiley&Sons;2014.p.352.

29.GoicoleaI,Briones-VozmedianoE,OhmanA,etal.Mappingandexploringhealth systems’responsetointimatepartnerviolenceinSpain.BMCPublicHealth.

2013;13:1162.(Accessed26/10/2016).Availableat:http://bmcpublichealth.

biomedcentral.com/articles/10.1186/1471-2458-13-1162

30.PasarínMI,ForcadaC,MontanerI,etal.Saludcomunitaria:unaintegraciónde lascompetenciasdeatenciónprimariaydesaludpública.InformeSESPAS2010.

GacetaSanitaria.2010;24(Supl1):23–7.

31.Torrent EL,Vega CF, MillerF, et al. Factores quefacilitan y diﬁcultanel desarrollodelosproyectoscomunitarios.EstudioobservacionaldelaredAUPA decentrosde atenciónprimariadeCatalu ˜na.AtencionPrimaria.2010;42:

218–25.

32.MarchS,RamosM,SolerM,etal.Revisióndocumentaldeexperienciasde actividadcomunitariaenatenciónprimariadesalud.AtenPrimaria.2011;43:

289–96.

33.AdellCN,Rua MP,SolerJC,etal. Lasaludcomunitariaenlosequiposde atenciónprimaria:objetivodedirección.AtenPrimaria.2016.Availableat:

http://dx.doi.org/10.1016/j.aprim.2015.10.009.

34.SupperI,CatalaO,LustmanM,etal.Interprofessionalcollaborationinprimary healthcare:areviewoffacilitatorsandbarriersperceivedbyinvolvedactors.

JPublicHealth.2015;37:716–27.