A multi-country mixed method evaluation of the HERA (Healthcare Responding to Domestic Violence and Abuse) intervention: A comparative analysis

Background: 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. Methods: 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. Results: 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. Conclusion: 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.