HERA (Healthcare Responding to Violence and Abuse) includes the following components: (i) training and reinforcement to support primary health care providers in identifying and responding to domestic violence (ii) awareness raising with women patients attending the clinics (iii) documentation of domestic violence and (iv) a care pathway for women who disclose domestic violence. Intervention development was informed by findings from the formative phase which involved structured health facility observations at the two clinics, and semi-structured interviews with primary health care providers, health managers, senior policy-makers with expertise in domestic violence programming and non-governmental organisations offering domestic violence services. The formative phase used a health systems readiness framework to identify system obstacles to successful implementation. The findings were presented at a workshop with 19 key stakeholders from various government ministries and non-governmental organisations working in the field of domestic violence. The aim of the workshop was to refine the intervention pathway and gain consensus regarding the preconditions required to support implementation and achieve the intended long-term outcomes [29]. It also helped to resolve areas of uncertainty (e.g. resource implications; role of different providers; geographical/logistic barriers for referral of survivors; and locus of further support for women). These findings are reported in a separate publication [5]. The intervention also drew on WHO recommendations for a health system response to intimate partner violence [30] and a UK evidence-based domestic violence intervention for general practice called IRIS – Identification and Referral to Improve Safety [8, 31].

The training was developed by Juzoor for Health and Social Development with input from the research team. Juzoor is a non-governmental organisation based in Jerusalem working at the national level to improve the health and well-being of Palestinian families. An important strand of their work includes empowerment of women and protection from gender-based violence. Training sessions were delivered jointly by Juzoor and a medical doctor using didactic and experiential learning activities. Information was provided on prevalence and health impacts of domestic violence on women and children, and common presentations consistent with experiences of domestic violence. Practical sessions used group work which focused on how to sensitively ask about and respond to domestic violence including use of the care pathway and documentation. The care pathway was a core mechanism within the intervention, an organisational device to refer women experiencing domestic violence in a safe and practical way to sources of support within and outside of the health system (Fig. 3). Health care providers who identified women affected by domestic violence were trained to refer them to the clinic case manager (a nurse) who was responsible for providing a first line response, consistent with WHO guidelines on health care for women experiencing IPV [32]. This entailed empathic listening, inquiring about needs, assessing safety and offering referral to the gender based violence (GBV) focal point that was situated externally in the Health Directorate. GBV focal points coordinated additional referrals within and outside of the health system and provided advice to clinic case managers. Drawing on the experiential learning cycle [33], two training sessions for all clinic staff were delivered 3 weeks apart - to allow for reflection - between April and May 2018. Three reinforcement sessions were delivered between June and September 2018 to facilitate discussion of cases and implementation challenges. Thirteen of 17 providers in Clinic 1, and 16 of 20 providers in Clinic 2 attended two initial training sessions in April and May 2018. In total, 24 attended the first reinforcement session, 18 the second and 17 the third. The training team also conducted three domestic violence and health awareness raising sessions with 50 women patients attending the clinics. Posters on domestic violence were placed in the waiting areas of the clinics and the training team developed a brief clinic handbook, outlining the referral pathway and roles and responsibilities within it.

HERA care pathway

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