Table 3 Triangulation of the three data sources (interviews, pre- and post-PIM, Identification and Referral data) based on assumptions and outcomes of the theory of change

Increased confidence and readiness among HCPs to inquire about, document and offer a first line response to women and referral experiencing DV*

HCPs reported being more confident to deal with DV cases and they also reported that after the training they gained skills in building trust with women so they can disclose violence. They believed that their documentation had improved.

HCPs reported that they felt more ready to make internal referrals after the training

There was increased confidence shown in matched pre- and post- PIM data in answers to: How ready do you feel now (after attending the HERA training) to perform the following tasks (ask about DV and make referrals) when dealing with female patients who are experiencing DV?

(See Figs. 3 and 4)

present

Women develop trust in, and want to confide in their HCPs about DV*

HCPs reported that they were able to gain women’s trust and give them space to confide in their experience of violence

There was an overall decrease in identification of women experiencing DV

(see Fig. 8)

Inconsistent

Increased identification & referral of women to case manager and the GBV focal point (MoH)*

Identification and referral numbers did not increase after the training. Mostly due to the Covid-19 pandemic, change in MoH clinic work days/priorities/responsibilities

One doctor reported that they were increasing identification in their non-MoH clinical work.

There was no increase in external referral.

HCPs thought this was due to fear of external referral and women’s and HCP perception of unreliability of external referral destinations.

The number of cases identified and documented in clinics:

pre-intervention: 83

during and post-intervention: 56

(see Fig. 8)

Absent

Women access the external referrals offered to them by the GBV focal point*

GBV focal point staff stated that few women experiencing DV accept external referrals

Only one external referral was made after training

Absent

Reduced fear among women (i.e. of exposure/retaliation) about help seeking*

HCPs reported that women who disclosed still feared retaliation from their husbands, family and causing a scandal

Absent

HCPs make sense of and understand their role and those of others in the HERA care pathway**

HCP reported that they better understood their roles and boundaries after the training

Present

Change in HCP values and attitudes about gender-based violence**

Several HCPs appeared to change their attitudes towards GBV and were more open to be a part of the health system response to it [from field notes]

Present

HCPs understand women’s need for safety and confidentiality in responding to DV**

HCPs reported becoming more aware of women’s need for safety and confidentiality

The decreased confidence by some HCPs about having a confidential space reflects an increased understanding of women’s needs of safety and confidentiality, rather than any change in the availability of those spaces.

(See Fig. 5)

Present

Ministry of Health actively supports implementation of HERA and legitimises the role of clinic case managers and the GBV focal point **

HCPs reported that they did not have enough support to attend the training. (protected time, suitable place, logistics, etc.)

MoH supported the creation of the new “case manager” role and assigned one for each of the 4 clinics but have not provided enough support

Absent

Motivated HCPs develop a shared sense of commitment to addressing DV**

Some motivated HCP reported that they felt a sense of duty to help women experiencing DV, but others did not.

inconsistent

HCPs work collectively to integrate HERA practices into their workflow**

HCPs followed the referral pathway in the clinics.

According to trainers and HCP there was discussion of cases among staff, during the training and also later in practice

Present

HCPs engage in critical reflection/discussion of DV cases with trainers and GBV Focal Points**

During the training, HCPs engaged in discussions of DV cases encountered in the clinics with the trainers

Present

HCPs feel safe and supported in responding to women experiencing DV**

HCP reported fear of retaliation from DV victims’ families and perpetrators

HCP reported that there is no protection or support from administration when they deal with DV cases

Having official certificate/training legitimizes the HCP DV work and makes HCP feel safe

There were multiple trends of changes among matched pre and post PIM results answering the question: Do you feel afraid of dealing with a domestic violence case?

(See Fig. 6)

Absent

There is streamlined coordination and effective communication practices between clinics, the MoH GBV focal points and external referral services that provide support to women experiencing DV***

HCPs, case managers and DV focal points reported effective coordination and communication practices along the referral pathway.

However, external referral (outside MoH) was reported to be difficult and occasionally ineffective.

inconsistent

Clinics have the resources and capacity to absorb the intervention (e.g. time, staff, budgets, physical space etc…)***

HCP reported that there are limited resources for primary care clinics. There is a shortage of staff and increased workload.

Additionally, some HCP reported not having the physical space for confidential disclosure of DV

Matched pre and post PIM results show decreased confidence by some HCP about having a confidential space

(See Fig. 5)

Absent

HCP are able to procure confidential space in the clinic to talk to women about DV***

It was reported by HCP that in various settings there are no spaces for private and confidential disclosure of DV

Results for PIM question number 4 shows lack of confidential space

(See table s6 in the appendix)

Absent

Women regard primary health care clinics as a safe place to access help for DV***

HCPs (+ case managers + GBV focal points) reported that women regard primary health care clinics as a safe place to disclose violence, and in some cases receive help

There is a documented reduction in identification

(See Fig. 8)

Inconsistent

Women feel comfortable having DV documented confidentially and understand its importance***

HCPs reported that not all women are comfortable in documenting DV. Measures were taken to alleviate that including: securing confidentiality, using different names, keeping the clinic records in a safe place, restricted access to National registries of women experiencing DV.

inconsistent

Training and ongoing support enhances HCP skills in offering a trauma-informed and non-judgemental response to women***

HCP reported better skills in dealing and responding to GBV disclosure after the training

Matched pre- and post-PIM results show increased readiness to respond to disclosure of domestic violence

(See Fig. 7)

Present