Key findings

• HERA increased the identification of women experiencing domestic violence across three countries, achieving increases of 69% in Sri Lanka, 78% in Brazil and 100% in Nepal, while the occupied Palestinian Territories experienced a 24% decrease, partly due to escalating violence in the Israeli occupation.
• Healthcare worker confidence and motivation to address domestic violence improved, with reported increases in readiness to identify, inquire about and respond to domestic violence by documenting cases, making referrals, and offering ongoing support. In Nepal, there was a slight decrease in healthcare worker confidence to offer ongoing support due to the healthcare clinics becoming Covid isolation wards.

A women-centred perspective

• Care for women went beyond simply identifying, documenting, and referring cases of domestic violence. It embraced a holistic approach, focusing on empathy, understanding social contexts, shared decision-making, and respecting women’s autonomy.
• Women reported that supportive, compassionate interactions were crucial in creating person-centred and empowering experiences during disclosure.
• Not all women wanted to pursue the referrals offered; many preferred ongoing supports from the healthcare workers they initially disclosed to.

Training and support for healthcare workers

• The training emphasised the need for understanding how unequal power dynamics between men and women drive domestic violence, and how to avoid replicating these in the health system, driving the need for women-centred care.
• Implementing a women-centred response required creating spaces for healthcare workers to reflect collectively on their practices and problem solve.
• In Brazil, supervision sessions integrated into existing multidisciplinary clinical meetings of the NPV (Violence Prevention Nucleus) helped sustain ongoing reflection and discussions on domestic violence cases, supporting implementation of HERA.
• In the other countries, these structures were lacking, and collective reflection relied on periodic refresher training, often delivered by external facilitators, indicating a lack of health system support to embed continuous learning and supervision.
• Some healthcare workers, particularly in Nepal, Sri Lanka, and occupied Palestinian Territories, struggled to adopt new approaches, as their views on domestic violence and gender norms were shaped by deeply ingrained cultural values about family roles, honour, and traditional gender hierarchies.

Interventions for managers

• Effective leadership was crucial for driving organisational change in the clinics. Leaders played a key role in shaping how staff understood their roles and encouraged shifts in beliefs and practices, guiding appropriate actions in different situations.
• Leadership support varied across and within countries, often reflecting the motivations and values of managers at different levels. Examples include the creation of clinic case managers in occupied Palestian Territories, extending training from private to public healthcare facilities in Nepal, making space within clinical meetings for case discussion in Brazil, and involving the Family Health Bureau of the Ministry of Health in Sri Lanka in the development and delivery of training.
• Provider Intervention Measure (PIM) surveys revealed that healthcare workers in all countries felt more supported by their organisations in handling domestic violence cases after HERA, except in occupied Palestinian Territories, where they felt less protected. This decline in perceived protection was linked to a significant escalation in violence resulting from the Israeli occupation that coincided with the study period.

Recording practices

• The presence of multiple clinical record systems for different purposes led to inconsistent and poor domestic violence documentation practices. Healthcare workers often navigated these complexities differently, and many were hesitant to document violence due to fears of community exposure or retaliation from the aggressor. In some cases, documentation was negotiated with women, leading to incidents of violence going unrecorded.

Implications for future research

• Account for the interaction between context and intervention goals when developing, implementing, and evaluating health system responses to violence against women.
• Investigate what defines positive outcomes for women at various stages of readiness to seek help and awareness of their situations, considering their diverse contexts, to develop tailored interventions.
• Determine which targeted health system interventions - such as leadership development, peer support, and communities of practice - are most effective in sustaining organisational change.

Details of the research

The study took place in health services serving socioeconomically disadvantaged communities, focusing on sexual and reproductive health care. This included primary healthcare facilities in Brazil, Nepal, and the occupied Palestinian Territories, as well as in district general hospitals in Sri Lanka.

Healthcare workers followed the WHO Clinical Handbook to deliver a women-centred response.  

HERA was shaped by a formative research phase and stakeholder workshops, tailoring the approach to each country.

From 2019 to 2022, each country conducted a mixed-method evaluation to assess both processes and outcomes. Data collection included the Provider Intervention Measure (PIM) to quantify changes in healthcare workers attitudes and behaviours, as well as clinic records to assess the identification and documentation of domestic violence.

Qualitative data were gathered through semi-structured interviews with healthcare workers, managers and women survivors, along with field notes and focus groups with key stakeholders conducted across all four countries.