The study design is a qualitative process evaluation which was undertaken between April and December 2018, consisting of interviews with a range of key stakeholders at both clinics. The design allowed a detailed exploration of the factors that shaped the translation of HERA into a real-world set of activities. Interviews were conducted in a private room within the clinics and audio-recorded with consent. We collected anonymised clinic data on identification and referral of domestic violence cases. This was collected from the clinic case registers which were used at the clinics to confidentially record disclosures of domestic violence. A member of the local research team requested anonymised clinic data on documented cases pertaining to the period of the evaluation. Provider attendance at the training sessions were collected from the domestic violence trainers. The 29 trained providers, the clinic case manager at each clinic, the domestic violence trainers and the GBV focal points from the two Directorates were invited to participate in a semi-structured interview. Clinic case managers helped to recruit women aged 18 years and over who were referred to them after disclosing domestic violence to a provider, and liaised with the research team to arrange interviews at the clinic. Non-eligible women included those who were assessed by case managers as being too psychologically distressed or affected with mental health issues which would make it difficult for them to give informed consent, although none of the women met these criteria. Twenty-one women who disclosed domestic violence and saw a case manager were approached (15 in Clinic 1 and 6 in Clinic 2). Overall, 18 semi-structured interviews were conducted with five women; seven primary health care providers, two clinic case managers, two GBV focal points and the two trainers (see Table 1). The interview guide for providers included questions related to the training and the extent to which it prepared them to deal with domestic violence cases; experiences of dealing with domestic violence cases; challenges in identifying and responding to women affected by domestic violence; documentation of domestic violence; perceptions of roles and responsibilities within the referral pathway and how the pathway worked in practice; and issues pertaining to personal safety and support for providers. The women’s interview guide included topics related to their experiences of talking to primary health providers at the clinic about domestic violence and the response they received; their feelings about referral options offered and experiences of accessing support within and outside of the health system; barriers to accessing support; changes to their situation following disclosure to a provider; issues of safety and confidentiality; and documentation of domestic violence. The interviews with providers and women patients were conducted in Arabic (AA, AS, ASA, HO, RH, IJ); the trainers were interviewed in English.

Characteristics of participants

GBV Gender based violence

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