Evaluation of a domestic violence training and support intervention in Palestinian primary care clinics: a mixed method study
Authors: Joudeh Nagham , Shaheen Amira , Bacchus Loraine J , Colombini Manuela , Alkaiyat Abdulsalam , Lambert Helen , Hashlamoon Rasha , Feder Gene 
Published: October 2023

Abstract
Background
Domestic violence (DV) is a violation of human rights and a major public health problem that damages the health of women and their families. In the occupied Palestinian territories, 29% of women have a lifetime exposure to intimate partner violence, the most prevalent form of DV. Despite the existence of national policies to prevent and respond to DV, implementation within the Palestinian primary health care system has been weak. We developed, piloted, and evaluated a system-level intervention, including training for health care providers and care pathways for women patients. The aim of our evaluation was to determine the feasibility and acceptability of the Healthcare Responding to Violence and Abuse (HERA) intervention.
Methods
Formative phase: adaptation of a previous (HERA) intervention implemented in primary health care settings in Palestine, informed by stakeholder meetings, interviews with clinic managers and health care providers (HCP), facility-level readiness data, and findings of a previous pilot study. The training component of the intervention, delivered by the Palestinian Counseling Centre, included a train-the-trainer session, two clinic-based training sessions, and reinforcement sessions for front-line healthcare providers in four clinics.
Intervention: Healthcare providers were trained to ask about DV, give immediate support, and offer a referral to a nurse case manager. The care pathway beyond the case manager was either referral to a primary-care based psychologist or social worker or to a gender-based violence focal point external to the clinic who coordinated referrals to appropriate external services (e.g. police, safe house, psychologist, social worker).
Evaluation phase: Thematic analysis of post-intervention semi-structured interviews with (HCP) and trainers; observations of training sessions and field notes. Provider Intervention Measure (PIM) data on changes in HCP attitudes and practice were analysed with descriptive statistics. Identification and referral rates for women disclosing DV 12 months before and 12 months after the intervention were obtained from clinic registries. We developed a theory of change to triangulate our qualitative and quantitative data.
Results
The training proved acceptable to HCP and there was evidence of positive change in attitudes and readiness to engage with women patients experiencing DV. Compared to the year before the intervention, there was a reduction in the number of patients disclosing DV during the intervention and of referrals in three of the four clinics. This reduction may be explained by the impact of the Covid 19 pandemic on clinic priorities, lack of time, persisting HCP fear about engaging with DV, and HCP rotation between clinics.
Conclusion
The delivery of the training component of the HERA intervention within the Palestinian primary healthcare system proved partly feasible and was acceptable to HCP, but contextual factors limited HCP application of the training in practice.