Bacchus Loraine J, Pereira Stephanie, Joudeh Nagham, Kalichman Beatriz Diniz, K C Samita, Siriwardhana Prabhash, Silva Tharuka, Lucas d'Oliveira Ana Flavia Pires, Rishal Poonam, Shrestha Satya, Schraiber Lilia Blima, Alkaiyat Abdulsalam, Rajapakse Thilini, Shaheen Amira, Feder Gene, Lambert Helen, Moreno Claudia Garcia, Colombini Manuela
Department of Global Health and Development, London School of Hygiene & Tropical Medicine, UK.
Department of Preventive Medicine, School of Medicine, University of São Paulo, Brazil.
SSM Health Syst. 2025 Jun;4:100042. doi: 10.1016/j.ssmhs.2024.100042.
Domestic violence (DV) against women has adverse health consequences and demands a comprehensive healthcare response. Interventions adapted from high-income countries encounter implementation challenges in low-and-middle-income countries, due to diverse socio-cultural, political and economic contexts. This study explored HERA (Healthcare Responding to Violence and Abuse) implementation, that aimed to strengthen the healthcare response to DV in Brazil, Nepal, the occupied Palestinian territory (oPt), and Sri Lanka.
Parallel mixed method study (2019 - 2022). Quantitative data included the Provider Intervention Measure (PIM), training attendance records and DV documentation before and after the intervention. Qualitative data included semi-structured interviews with providers and DV survivors, field notes and stakeholder meetings. Data were integrated at the level of interpretation and reporting using a narrative approach, drawing on theories of Complex Adaptive Systems and sensemaking.
HERA enhanced healthcare provider readiness to address DV and fostered a women-centred approach. The interaction between HERA and the diverse contexts impacted the reciprocal relationship between sensemaking and sensegiving within health systems, leading to adaptive behaviours among providers and women. This included mediation practices, negotiating DV documentation, modified roles, and containment of DV cases within the clinic. Normative gender roles, normalised DV attitudes, biomedical sensemaking frameworks, community violence, austerity policies, scarce resources, and weak leadership and management support affected implementation success.
It is important to consider the interplay between context and intervention goals during development, implementation and evaluation of health system responses to DV. Managers require specific intervention components to support organisational change. Culturally appropriate support for women should acknowledge limitations to their agency.
针对妇女的家庭暴力会对健康产生不良后果，需要医疗保健领域做出全面应对。由于社会文化、政治和经济背景各异，从高收入国家借鉴的干预措施在低收入和中等收入国家面临实施挑战。本研究探讨了HERA（应对暴力和虐待的医疗保健项目）的实施情况，该项目旨在加强巴西、尼泊尔、巴勒斯坦被占领土（oPt）和斯里兰卡对家庭暴力的医疗保健应对。
平行混合方法研究（2019 - 2022年）。定量数据包括提供者干预措施（PIM）、培训出勤记录以及干预前后的家庭暴力记录。定性数据包括对提供者和家庭暴力幸存者的半结构化访谈、实地记录和利益相关者会议。运用复杂适应系统理论和意义建构理论，采用叙事方法在解释和报告层面整合数据。
HERA提高了医疗保健提供者应对家庭暴力的准备程度，并促进了以妇女为中心的方法。HERA与不同背景之间的相互作用影响了卫生系统中意义建构和意义赋予之间的相互关系，导致提供者和妇女出现适应性行为。这包括调解做法、协商家庭暴力记录、角色调整以及在诊所内处理家庭暴力案件。规范性性别角色、常态化的家庭暴力态度、生物医学意义建构框架、社区暴力、紧缩政策、资源稀缺以及领导力和管理支持薄弱影响了实施的成功。
在制定、实施和评估卫生系统对家庭暴力的应对措施时，考虑背景与干预目标之间的相互作用非常重要。管理者需要特定的干预组成部分来支持组织变革。对妇女的文化适当支持应承认她们行动能力的局限性。
