Men's intimate partner violence (IPV) against women, is a global public health problem and has devastating effects on the health and wellbeing of women and children.1–3 Health care services, and especially primary health care facilities, can play a key role in alleviating the effects of IPV, since they are the gatekeepers of the health system and therefore the public institutions most frequently accessed by women exposed to IPV, even if not all of them will disclose this situation.1,4–7 In this study IPV was defined as “any behaviour within an intimate relationship that causes physical, sexual or psychological harm, including acts of physical aggression, sexual coercion, psychological abuse and controlling behaviours”,3 and it was explicitly stated that the focus was on IPV exerted by men against women.

When it comes to implementing promotive and preventive interventions against complex problems that transcend the traditional responsibilities of the health system, a primary health care (PHC) approach characterized by the attributes of person/family-centred, longitudinal, comprehensive, coordinated and community-oriented care, is considered to be more effective.8–10 The attributes of PHC initially proposed by Barbara Starfield as a set of dimensions to measure adequacy of the primary care organization and its characteristics for service delivery, have been extensively described as positively associated to successful provision of preventive services.10,11 Under these attributes, multidisciplinary teams working in PHC act as a key interface linking ambulatory care with hospital and specialty services, and individual care with other community-social services. Some studies point out that these features of PHC could positively contribute to the implementation of comprehensive responses to IPV.12–14

Since the early 80's when the health care system in Spain underwent a major transformation, health delivery has become sectorized and focus has been placed on first-line health care facilities −called primary health care centres (PHCC)− where the health care workforce is organized around multidisciplinary teams.15 The Spanish PHCC have been developing and expanding, showing improved integration of services, good coordination of care, and an appropriate family-orientation within the services. In regards to the health care response to IPV in Spain, the actions have included: training of health care professionals, developing protocols, and establishing monitoring systems.

As of 2015, there are 13,187 PHCC in Spain, and the health system has performed well in international comparisons.16–19 Primary care scores for Spain are among the highest in Europe in terms of governance, access, continuity and structural aspects, medium in terms of coordination and comprehensiveness and lower in terms of efficiency.19 The current financial crisis has led to austerity measures within the Spanish health care system, including reduced public spending, salary reductions and reduced services for certain groups like undocumented migrants.16,18,20–22 This situation constitutes a challenge for effectively dealing with health problems in general,20 and IPV in particular.

This study aims to provide a snapshot of the different perceptions of professionals working in first-line health facilities on how the current operationalization of PHC attributes in Spain could influence the responses to IPV.

From the analysis of the interviews four categories emerged: Committed to the PHC approach but facing difficulties to implement it, Community work relying on voluntarism, Multidisciplinary team work, and Continuity of care hindered by heavy work load. Table 4 displays the categories, subcategories and selected codes, while Table 5 displays selected quotations for each category.

This study captures both professionals’ perceptions on the current (weak) presentation of PHC attributes in Spain and their views on how such attributes, when actually present, can promote a comprehensive response to IPV.

In line with our findings, other studies evidence that a PHC approach facilitates the integration of healthcare responses to complex health problems, i.e. mental health.25 Previous studies in Spain support the importance of the PHC approach as a relevant condition triggering better responses to IPV.13,14 However, participants also acknowledged the challenges to sustain the PHC approach in Spain due to the weak training provided both during undergraduate studies and in-service. Moreover, the implementation of a person-centred bio-psycho-social approach might risk focusing on solutions at the individual level, while the root of many health problems in general and IPV in particular lies mainly at the broader social level.26

Complaints about the effect of health care austerity measures on the work load of primary health care teams in Spain have been reported in other studies.20 This study describes how health care professionals perceived their deleterious effect for the sustainability of the PHC attributes and for responding to IPV. However, such complains could also represent ways to justify evading responsibilities, in an issue that remains controversial. One cannot forget that the health system reproduces the gender order of a given society, strongly influencing professionals’ practices, attitudes and priorities.27,28

Community-orientation is commonly recognized as one of the most challenging attributes to achieve when implementing a PHC approach within health systems.8,16 Previous studies in Spain show that this attribute has been not in focus within the Spanish PHC in general, and even less in regards to IPV.29 Lack of support from the managerial level and the fact that community work has not been included within the objectives evaluated annually have been mentioned as hindering community-orientation of PHC in Spain.30,31 This study coincides with these findings but also points out another key issue: community work in relation with IPV is considered important and PHC teams do engage in such initiatives, although in a voluntary basis, very much depending on individual professionals’ commitment, which makes work hard to sustain. As the WHO guidelines point out, a health care response should involve not only detection and referral, but also preventive and community work.7 Such work can contribute to professionals’ perceived self-efficacy in dealing with IPV, since they might feel that they have ‘something to offer’.13,14 The existence of various community activities and localized initiatives to promote community work might facilitate changes towards a stronger community-orientation.32,33

Multidisciplinary team work is important to offer an IPV response centred on the diverse needs of women exposed to IPV1,7; i.e., the nurse and medical doctor can detect and follow up, the social worker can work therapeutically and connect the woman with other resources, the paediatrician can explore the effects of IPV on her children. The organization of the Spanish PHC services allows patients to meet different professionals in the same facility; the integration of social workers within PHC teams seems especially relevant for offering a comprehensive health care response to IPV and for connecting the PHCC with other resources. However, the mere existence of different professions under the same roof does not ensure that cases of IPV receive a multidisciplinary and coordinated response. In order to do so, team-supporting structures should be developed, establishing clear goals, division of labor, training of team members in their personal roles and in team functioning. Such structures appeared to be weak in Spain, and were too dependent on professionals’ voluntarism, which hinders their sustainability and effectiveness. A review of facilitators and barriers to inter-professional collaboration pointed out that perceived hierarchy was the main conceptual barrier hindering collaboration, which was also pointed out in our study and others.27,34 Multidisciplinary training could facilitate change on health professionals’ perceptions and enhance awareness of each other's roles.34

The most committed professionals in this study also highlighted the importance of building and keeping trust with women who disclose IPV and that referring or consultation with other professionals should not become an easy scape. Building trust is also mentioned as part of the WHO recommendations.7

This study showed that the way PHCCs are organized in Spain allows longitudinal continuity and ensures the establishment of long term relationship with patients that, to a certain extent, compensate for the short(ening) consultation times. On the one hand, the findings from this study coincide with other studies that show that building trust relationships between health professionals and women exposed to IPV is key in order to improve IPV detection and response.4,5 On the other hand, this study also points out that close relationships between professionals and patients might prevent detection due to over confidence or fear of damaging the relationship from the point of view of the professional. The family-focused PHCCs in Spain might enhance professionals’ knowledge of the patient's situation but also possesses great challenges to the implementation of IPV responses; i.e. safety for both the professionals and the victims might be put at risk. It is important to note that the WHO guidelines fail to address this aspect thoroughly.7

This study was based in a specific setting, Spain, a country with a decentralized and universal public health system, an extensive network of PHCCs, and where health policies against IPV have flourished. These characteristics are shared by a number of Western EU countries, and thus our results may be transferable to them.

As we have described before, this research was part of a larger study in which exploring the linkage between the attributes of PHC and IPV was not the main focus; thus, we may have failed to inquire in greater depth on relevant issues. However, the central role of the PHC attributes in shaping PHC team responses to IPV, and the challenges to sustaining such attributes emerged from the data, and this was what motivated this study. We argue that following an emergent design adds to the study's dependability, which contributes to research trustworthiness.23

Since the participation was voluntary it is likely that the sample over represents the perceptions of those professionals more sensitized with IPV. The higher proportion of women in the sample might reflect this as well. However, an effort was made to invite professionals who were more skeptical with the topic, although this was not always successful.

Due to the study design we cannot claim that a causal relation exists between PHC attributes and IPV responses. However, we consider that this study is a first step for improving our understanding on how PHC attributes can contribute to better health care responses to IPV and the complexity of their implementation in the day to day practices of PHCC teams.

María Teresa Ruiz Cantero.

The corresponding author on behalf of the other authors guarantee the accuracy, transparency and honesty of the data and information contained in the study, that no relevant information has been omitted and that all discrepancies between authors have been adequately resolved and described.

I. Goicolea was the PI in this project, proposed the idea for this manuscript, organized the structure and developed the first draft. E. Briones-Vozmediano, L. Otero-Garcia and M. Garcia have been involved in the entire project, participated in data collection and analysis and have critically revised successive manuscripts. P. Mosquera and C. Vives-Cases have been involved in the entire project, have participated in the analysis of the data have critically revised the successive manuscripts. All authors have approved the final version of the manuscript and all agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

This study has been funded through a COFAS grant (supported by COFUND action within the Marie Curie Action People, in the Seventh Framework programme and the Swedish Council for Working Life and Social Research/FAS-Forskningsradet för arbetsliv och socialvetenskap) through a competitive call. This work was partly supported by the Umeå Center for Global Health Research, funded by FAS, the Swedish Council for Working Life and Social Research (Grant no. 2006-1512).

The authors declare that there is no conflict of interest. One of the authors (E. Briones-Vozmediano) belongs to the Gaceta Sanitaria editorial committee, but was not involved in the editorial process of the manuscript.