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.1–5 The health care system, especially primary health care facilities, can play a key role in responding to IPV, since they are the public institutions most frequently accessed by women exposed to IPV —even if most of those cases remain undetected by health professionals.1,6,7 The World Health guidelines Responding to intimate partner violence and sexual violence against women defines what an “adequate healthcare response to IPV” should include: detect, provide health-care assistance and register, orient on available resources, coordinate with other professionals and institutions, and ensure that all the previous actions are carried out putting women's needs at the centre (woman-centred).5

Evaluations to assess the level of implementation of a health care response and, most importantly, on the factors triggering an adequate health care response to IPV —understood as the one that fulfils the WHO recommendations—5,8–10 are scarce. In addition, research methodologies that account for the role that contextual factors play instead of controlling them, have still been scarcely used to assess the health-care response to IPV.

This article aims to fill this knowledge gap by: 1) describing a realist evaluation carried out in Spain aiming to ascertain why, how and under which circumstances primary health care teams respond to intimate partner violence, and 2) discussing the strengths and challenges of the application of this approach to explore the health care response to IPV.

PT1 was the starting point of this realist evaluation and described how the implemented interventions within primary health care teams in Spain have focused on developing protocols, monitoring systems, and training professionals on IPV. Our initial hypothesis was that such interventions generate team learning about IPV within primary healthcare teams, and that this team learning process was expected to lead to changes in team culture, teamwork and practice with regard to IPV. However, PT1 did not accurately account for what was actually happening within primary health care teams, and how (if at all) those potential mechanisms and contextual factors might be interacting together to trigger adequate health care responses to IPV.

PT2 emerged as a refinement of PT1 and stressed that even if the interventions carried out might have played a role in shaping individual and team responses to IPV, such responses were strongly influenced by other factors. Team and individual level factors (such as motivation, team climate28 and team leadership) shaped the teams’ capacity to create spaces for team learning and teamwork (and also the interest in this), and to provide therapeutic responses to IPV rather than merely referrals to specialised services. We found that individual motivation was key in shaping professionals’ responses. Regional interventions legitimised the work of motivated professionals but did not encourage them to engage in individual and/or team responses to IPV. We found that other interventions not directly related to IPV (such as interventions to strength woman-centred care) can facilitate the integration of team responses to IPV.

In order to explore whether different mechanisms and contextual factors were present in cases with different degrees of IPV responses, we put PT2 to the test in three additional cases, located in the same region as La Virgen but with perceived different achievements in terms of their responsiveness to IPV. The PT3 that emerged from the analysis of those four cases explained how the interventions to integrate a response to IPV within first-line health-care teams a) were implemented differently depending on individual and team-level factors, b) were more easily adopted when woman-centred care had been previously implemented in the team, c) were more easily implemented and sustained in environments that promoted team-work, d) required a sufficient number of motivated professionals and an enabling managerial style in the team to be sustained, e) legitimised the response of internally motivated providers, and f) had limited impact on non-internally motivated providers.

In order to further refine PT3 and to identify the key combination of factors and mechanisms in triggering an adequate IPV response to IPV, we applied it to an even larger number of cases. This was done in the last step and lead to the development of PT4. The final PT4 stated that primary health care teams that perceived themselves as well prepared to deal with IPV, consider themselves to be self-efficient enough to deal with IPV and have a woman-centred approach to IPV respond better to women exposed to IPV. These three mechanisms are necessary in order to trigger a better response, but they are not the only ones —there might be others that would trigger a good IPV response. In terms of the contextual factors —at the team level, in general, and in regards to the intervention specifically— the use of the protocol and accumulated experience in primary health care seem to be the most relevant contextual factors in triggering a good response, however in order to do so, they must be combined with other factors, such as having enough number of professionals who have received training on IPV, the presence of a committed social worker, or/and an enabling working environment.

See Table 2 for a summary of the successive PTs.

Realist evaluation has been considered to be well suited for evaluating complex interventions, as it allows for considering interactions between different layers of context, outcomes and the underlying mechanisms.12–14,29–31 In this study, the use of realist evaluation allowed us to capture the gaps between the planned intervention and its implementation as well as the relevance of contextual factors, and of other interventions (besides the ones directly targeting IPV) in shaping the individual and team responses to IPV. With the exception of a realist review of screening programmes by O’Campo et al.,32 to our knowledge this is the first time that realist evaluation has been used to assess health-care response to IPV.

One challenge when evaluating complex interventions refers to the difficulties in assessing outcomes. In this study, despite the existence of the WHO guidelines, it is still difficult to define what an “adequate response to IPV” is and even harder to measure it. In order to conduct a realist evaluation assessing outcomes is key. In this study, our outcome was assessed both qualitatively and quantitatively (via the PREMIS), and consequently the findings of our studies are applicable as long as our definition and measurement of “adequate response of IPV” can be considered relevant.

In addition, dealing with uncertainty and complexity means that the research team has to make changes to the planned study protocol in order to best embrace such complexity. In our case, it was possible to be flexible and adapt the study protocol to the emerging findings over the successive steps of the study. However, this required time, resources and expertise, which might not always be available when conducting evaluations within more limited time frames.

The successive rounds allowed us to explore different perspectives more in depth. In that sense, we do not consider PT4 the “best PT”. Each PT allowed us to more deeply explore different layers of the phenomenon. In addition, the knowledge generated during each of the cycles of refinement guided us in data collection and analysis during the following cycle. However, even if we claim that we followed an emergent design and that each successive step benefited from the knowledge gained in the previous one, the process was not ideal. Logistically, it was not possible to completely finalize each PT before starting data collection for testing the next PT. In that sense, some of the issues emerging from the successive rounds could not be completely accounted for during data collection. That leaves important aspects that deserve to be further explored, including the role of individual motivation in shaping a team's response.

Overall, the realist evaluation approach allowed to explore how different layers of contextual factors interacted with mechanisms to trigger an adequate response to IPV. However, the characteristics of the intervention posed an important challenge. The implementation of the health-care response to IPV in Spain was not a clear cut intervention but rather a group of actions emerging from the Gender Based Violence Law approved in 2004 and regional laws.18 The intervention was not well defined, did not start at the same time in all regions, varied in terms of the strategies chosen and the extent of its implementation by region, and evolved over time. In addition, austerity measures started impacting the Spanish health system in general, modifying key contextual factors such as team workloads, and primary health care investments.33 One of the limitations of this study is that we were not able to fully capture the time component and the regional differences. We have purposively overlooked these complexities in order to be able to focus on the already complex issues happening at the team level, since we also considered these issues to be relevant beyond the Spanish context.

Finally, PT4 constituted a summary of the key mechanisms and contextual factors needed to adequately generate IPV responses within primary health care teams. However, the relevance of such conditions could be further confirmed (or refuted) if more cases were included in future analysis. In addition, the role of other relevant conditions (not included in the analysis) could also be further explored with other cases.

This realist evaluation study allowed us to point out several key mechanisms —teams’ self-efficacy, perceived preparation, woman-centered care—, and contextual factors such as enabling a team environment and managerial style, motivated professionals, the use of the protocol and accumulated experience in primary health care, that should be considered in order to develop adequate primary health-care responses to IPV.

The full application of this realist evaluation was demanding in terms of time, funding and the expertise required. However, we claim that in this study the use of realist evaluation was useful in capturing variations, and the successive cycles allowed knowledge augmentation through a step-by-step scaling up. One strength of this approach is that it allows for flexibility in moving backwards and forwards between theory and empirical findings and in adapting to emerging unexpected findings. In addition, this approach is more suitable for exploring complex interventions as they are implemented in natural settings, as is the case with the implementation of health-care responses to IPV.

Carme Borrell.

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, participated in the conception and design of the work, the data collection, the analysis and interpretation of the data, the writing of the article and its critical review with important intellectual contributions. C. Vives-Cases, A.-K. Hurtig, M. San Sebastian and B. Marchal have participated in the conception and design of the work, the analysis and interpretation of the data and have critically review the article with important intellectual contributions. All authors have approved the final version of the manuscript. All authors are 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.

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