| Values |
Supportive attitudes towards health sector role in addressing DV among some senior officials Acknowledgement of DV as a public health problem among senior officials Some negative views among health managers Traditional attitudes among some health providers around DV (DV as family issue) Limited PHC role on DV—seen as a mental health issue (more appropriate for psychologists or social workers to deal with)
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Discussion on role of health providers during training sessions 3 clinic-based community awareness raising sessions on DV conducted (1 in Hebron area attended by 30 women and 2 in Bethlehem area attended by 50 women)
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| Leadership and governance |
No DV law, or any protective and safety measures for health providers’ safety NRS guidance on DV service co-ordination exists, although no specific national and subnational health guidelines on DV Some national accountability structure on DV exists but limited government endorsement Political occupation leading to difficult security arrangements Recent increased interest in VAW of MoH (as opposed to past leadership vacuum and no attention to it) New MoH governance structures (and policies) for addressing DV (e.g. GBV focal points at central level) but lack of MoH clear guidance on DV Limited willingness and lack of leadership among some district health managers (not wanting to get involved in DV cases) Recognition of the leadership role nurses could play in addressing DV in PHC Limited agency among GBV focal points (still need director approval for difficult DV cases)
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MoH willingness to support the development of specific DV clinical guidelines for health-care providers MoH recognition of limited providers’ security led to the consideration of passing a policy on health-care providers’ safety GBV focal points participated in the initial training sessions along with clinic case officers for DV to clarify roles Nomination of clinic case officers for DV (nurses) to lead DV response in the study clinics
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| Financing and other resources (staff, infrastructure, supplies) |
No dedicated budget for DV response; reliance on international donors Limited staff and no additional resources to fund any psychosocial services on site Lack of privacy at clinics when asking about DV
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MoH commitment to improve privacy at clinic level Importance of privacy stressed during intervention’s training and one clinic allocated a private room for counselling DV cases Clinic case officers for DV to counsel on DV in a private room
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| Co-ordination and community engagement |
NRS in place (guidelines), though limited intersectoral co-ordination and little communication across partners Limited implementation at clinics as MoH is not fully involved in NRS Limited referral services (also due to political occupation) Fear of community stigma impacting on DV service uptake None of the women wanted referral to GBV focal points or external referrals (because of limited mobility and fear of stigma) Limited HCP agency (and authority) to refer cases externally—still have to defer to GBV focal points Limited authority of GBV focal points as they also defer to high-level senior authority for difficult cases
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Reinforcement training sessions further clarified the role of clinic case officers for DV and the referral pathways (e.g. standard practice for all providers to always refer DV cases to clinic case officers for DV) Community awareness sessions organized at study clinics with support from MoH GBV focal points were included in all the initial training sessions—to make the link between the clinic roles and their role and let people know who they are
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| Health workforce |
Some (though limited) national MoH training on DV—mainly focus on identification and referral Training targeting nurses but not cascading to other staff Low staff knowledge and capacity on DV, paired with traditional attitudes towards DV led to staff not getting involved in DV cases High workload and limited staff time HCP fear of family retaliation and concern over own security leading to them refraining from identifying and/or documenting DV cases
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Integration of discussion on staff security in the training content Training intervention to raise DV awareness of all clinical staff not just nurses (e.g. laboratory technicians who had some contact with women patients) Use of actual histories of survivors of DV identified in the clinic (done safely and protecting survivors’ confidentiality) for discussion in reinforcement sessions
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| Information |
National DV health information system in place—though not uniformed and consistent MoH policy on DV documentation at facility level (with specific forms for recording DV cases) though limited policy implementation due to widespread underreporting of DV by women and front-line workers’ discretion in recording DV Lack of clarity among HCP on who should be documenting DV cases
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