Introduction

"The disadvantaged position of women in society is internationally recognized as both a breach of human rights and a barrier to broader social development" (^{World Health Organization, 2010, p. 1}).

Partner violence against women is the most serious form of gender inequality. The mortality rate is alarming. In Spain, 906 women have been killed by their partner or former partner from 2002 to 2016 (^{Ministerio de Sanidad, Servicios Sociales e Igualdad - Spain, 2017a}). 8 dependent children have been killed in 2014 and 2015 and 1 in 2016 (^{Ministerio de Sanidad, Servicios Sociales e Igualdad - Spain, 2017b}). The extent of the problem is such that the Spanish Organic Law 8/2015, of 22 July, modifying the system of protection of children and adolescents, includes children as direct victims of gender-based violence (^{Moreno-Torres Sánchez, 2015}).

Partner violence against women is defined as "any act of gender based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life" (^{United Nations, 1993}); it is, therefore, violence against women for the mere fact of being women ⁽⁸⁾ and it is perpetrated as an expression of discrimination against women due to the inferior position assigned to female sex in the society, the historical situation of inequality and the relationships of power of men over women (^{Spanish Law 5/2005, 2005}; ^{World Health Organization, 2005}).

It is perpetrated within the family, at social and state level, and includes, among other forms, partner violence against women, sexual harassment in the working or educational environment, aggressions or sexual abuse, trafficking and sexual exploitation of women and girls, femicides, female genital mutilation, crimes committed in the name of honour and dowry-related, early and forced marriage, female infanticide or selective abortion of female foetuses (^{Spanish Law 1/2004, 2004}; ^{World Health Organization, 2005}, p. 27).

Of all the ways mentioned, partner violence against women is the one that causes more preventable mortality. A woman is more likely to be injured, raped or killed by her partner or former partner than by another person (^{World Health Organization & Pan American Health Organization, 1998}).

The results of a multi-country study carried out by the World Health Organization (WHO) to more than 24.000 women from 15 sites located in 11 countries (Bangladesh, Brazil, Ethiopia, Japan, Namibia, Peru, Samoa, Serbia, Montenegro, Thailand and the United Republic of Tanzania) have found that between 15% and 71% of all ever-partnered women have experienced physical or sexual violence by their intimate partner, with rates that vary from 24% and 53% in most of the sites studied (^{World Health Organization, 2005}).

In Spain, according to data from the 2015 Macro-Survey on Violence against Women (^{de Miguel Luken, 2015}), 12.5% of all women aged 16 years or older living in Spain claims to have suffered physical or sexual violence by their intimate partner or former partner in their lifetime. Specifically, 10.4% of women have suffered physical violence, 8.1% sexual violence, 25.4% psychological violence (i.e. preventing them from seeing other people or going to certain places), 21.9% emotional psychological violence (i.e. insults or threats) and 10.8% economic violence. Additionally, 85.2% of the victims of physical violence, 94% of the victims of sexual violence and 95.4% of the victims of emotional psychological violence states that violent acts usually occur more than once. On the other hand, 13% of them has been afraid of their partner or ex-partner at some point in their lives and 2.9% claims to have felt fear on an ongoing basis. Due to the methodological improvements introduced and the new questionnaire used, new cases of violence against women that had remained hidden before they have been brought to light.

For 20 years, the ^{WHO (1996)} considers that violence against women is a public health problem, which has recently defined as «a global health problem of epidemic proportions» (^{García-Moreno et al., 2013}). Violence increases the poor perceived health and the risk of having some important health problems (^{Law 5/2005, 2005}; ^{García-Moreno et al., 2013}; ^{World Health Organization, 2005}). These problems include, among others, direct physical injuries (bruises, wounds, fractures...), abdominal pain and gastrointestinal problems, chronic pain, joint problems, neurological disorders, accidental pregnancies, teenage pregnancies, miscarriages and abortions, late foetal death, low birthweight or prematurity, intrauterine haemorrhage, HIV and other sexually transmitted diseases, anxiety, depression, alcohol abuse, drugs or psychotropic drugs, eating disorders, post-traumatic stress disorder, disability and death (^{García-Moreno et al., 2013}; ^{World Health Organization, 1996}). Additionally, less follow-up of the prevention activities, such as screening for cervical and breast cancer, has been observed in these women (^{García-Moreno et al., 2013}, pp. 21-22).

In short, it is a risk factor for women's poor health, which makes them go to health centres more frequently. In the last year, 88% of these women went to their family physician for different reasons, 53% due to a specialised consultation and 35% to hospital emergencies. Only 4.8% of women have ever been asked if they suffered partner violence (^{World Health Organization, 2013}, p. 1).

45% of them have decided to disclose their problem and to seek professional help. Psychiatric or psychology (29%), followed by health care (22%) and legal or social services (16% and 13%, respectively) were the most frequent services they used (^{de Miguel Luken, 2015}).

According to several studies, health care professionals report experiencing difficulties to identify partner violence against women and to take action on this (^{Arredondo Provecho et al., 2012}, pp. 85-99; ^{Pichiule et al., 2014}). Apart from this, traditional beliefs, which consider that partner violence against women is a private matter (^{Valdés Sánchez, García Fernández & Sierra Díaz, 2016}) or a social problem (^{Rodríguez-Bolaños, Márquez-Serrano & Kageyama-Escobar, 2005}), and the biological approach of health care represent a major obstacle in understanding the problem.

A number of international agencies have on many occasions highlighted the need for an effective training of health professionals to address this health problem (^{García-Moreno et al., 2013}; ^{World Health Organization, 2005}).

In Spain, the importance of training is included in the Spanish Organic Act 1/2004, of 28 December, on Integrated Protection Measures against Gender Violence (^{Cabrera Mercado & Carazo Liébana, 2010}), at the national level, and in counterpart’s laws at regional level. They include the incorporation of this training in the curricular areas of university studies and specialisation programs for social-health professions and of contents aimed at prevention, early detection, intervention and support to victims of this form of violence, as well as the development of awareness raising programs and ongoing training of health staff in order to foster the early diagnosis, care and rehabilitation of women in situations of gender-based violence.

Despite this need for training and awareness raising, which is key to providing an effective and quality response to such a complex problem, the literature on the degree of training and qualification of health care professionals in this field is relatively scarce. In this sense, the Community of Madrid has integrated it into the Annual Plan for Continuous Centralized Training. Also, the Community has published three guidelines for action, one specific for primary health care; another for specialised health care and a short one for emergency services.

The objective of this study was finding the degree of knowledge and thoughts about partner violence against women of the specialised health care professionals who work in a tertiary hospital of the Community of Madrid, knowing the organisational challenges they face when they have to take action as well as suggesting proposals to improve the early detection and the care for the people who suffer it.

Method

Results

Out of 1.569 professionals, 235 persons from different fields completed the survey: 40% were graduates in nursing, midwives and physiotherapists; 32.8% doctors; 8.9% patient-care technicians; 6% administrative assistants; 1.3% porters and 11.1% corresponded to other professional categories.

The overall response rate was 15%. By professional category, graduates (20.2%) and doctors (15.9%) had the highest percentage of response rates.

Regarding the sociodemographic data of the professionals surveyed, the distribution by sex was 81.5% of women compared to 18.5% of men. The average age was 41.9 with a standard deviation of 8.86, as shown in Table 1.

Table 1: Socio-demographic data of the professionals that completed the survey. 

Concerning previous experiences, 31.5% of the professionals surveyed knew cases of partner violence against women in their environment, and 24.7% had detected some cases whilst working. Of these professionals, 52.3% had detected two or more cases. Their intervention after the detection was as follows: 25.9% did nothing, 24.1% initiated the action protocol established in the hospital, 39.7% referred the patient to another professional and 19% wrote a medical report.

Among the reasons they mention not to address the problem, the most frequent ones are considering that they do not have the required training (29.5%) or that the problem do not fall under their competences (5.1%).

79.8% had not been trained. Having received training was positively related to the level of knowledge, with a statistically significant difference (p = .003), as shown in Figures 1 and 2.

Figure 1 Training for Health Care Professionals on Violence Against Women. 

Figure 2 Impact of training of the health care professionals that completed the survey in their degree of knowledge. 

On average, the knowledge degree was 4.79 ± DE 1.72. Out of the 10 questions that refer to the level of knowledge, only in two, Q-15 and Q-16, statistically significant differences were found between professional categories (p = .006 and p = .012 respectively), as shown in Table 2.

Table 2: Knowledge Degree according to the Occupational Group. 

In their daily work, 36% of the health professionals did not normally adopt a wait-and-see approach to diagnose these cases, and 28.9% did not consider partner violence against women in patients with physical injuries as a differential diagnosis. The majority of the respondents think that this problem is very important (82.5%) or quite important (17.1%). For 98.7% of respondents, these cases go unnoticed and for 84.5% of them, 10 to 70% of the cases that come to the hospitals are not diagnosed there.

50.9% of the professionals surveyed believe that there is no consensus on the plan of action to follow by the professionals involved in the health care of these women. 49.4% were not aware that the Commission against violence existed in the hospital, and although 81% knew that there is a protocol, only 20.5% of them were aware of it.

Around 86.6% of health care professionals think that any man may perpetrate violence against women and 80.8% of these professionals believe that this type of violence may affect any type of women. Nevertheless, there are still a lot of stereotypes regarding the victim and the abuser. Moreover, about 9% of the respondents believe that abused women do not have any higher education and 5.1% of the professionals that took the survey believe that they are housewives or immigrants. On the other hand, about 11.3% of those professionals believe that the abuser is a drinker, 1.7% states that he might be a drug user and .4% of the people that took the survey thinks that he is unemployed.

The majority of the people that took the survey (this is, about 97.8%) believe that cooperation between all the health care professionals is needed to solve this problem. The results per professional occupation can be found under Table 3.

Tabla 3: Opinion according to each Occupational Group. 

The main points that health care professionals consider to be crucial when assisting women who suffer violence are the following: identify and detect possible cases at an early stage (44.7%), listen and provide reassurance and support to the victims, as well as give information and advice, refer the cases to other health care professionals (16.2%), inform the authorities, report the cases (14%), coordinate with other healthcare professionals (9.8%), provide treatment both physically and psychologically (8.1%), establish a protocol to offer protection (6.4%), refer to social services (3%) and train the adequate professionals to train and treat these cases (2.6%) as well as educate children and teenagers to avoid this type of behaviour (2.1%).

These measures are to be taken as this is a health issue and health care professionals should be involved to treat it (23.8%); moreover, we, as professionals should be aware and be responsible of its consequences (18.3%), as this is an issue that may affect anyone and we have the moral obligation to face it (14.9%). Thus, this is a severe and common issue that requires change (14%) and in order to do so specific training is required (8.5%). Violence against women is a social scourge that nullifies the women and avoids her to show her worth in the male-dominated society we live in (7.7%); our actions as health care professionals can save lives (6.4%) as this is a severe social issue (5.1%) and thus we shall know the action protocol (3.4%), as well as the helplessness that women face and the number of preventable deaths (1.3%) that comes at a high cost ( .4%).

Around 42.5% of health care professionals believe that there are organizational or structural challenges in their workplace that do not allow to properly diagnose cases of violence against women, due to the high pressure to treat patients (35.3%), not knowing the action protocol and the lack of coordination between health care professionals (31.8%), as well as the lack of information and training (17.6%) and the resources available for these professionals (11.8%), lack of communication with the patient (3.55%), excessive paperwork (2.4%) and our overall passivity of our society regarding these issues (1.2%).

Health care professionals suggest to change the functional organisation and improve the detection protocols for cases of violence against women. In order to do so, several measures should be implemented, such as training (6.8%), more time available for each patient during the visits (5.1%), better overall conditions to improve patients’ privacy without having to face their abuser (3.4%), more social workers, having a psychologist to help in these situations, more information on the procedure to follow and further interdisciplinary coordination (2.6%), as well as guidelines on how to proceed and coordinate health care professionals (1.7%), having enough personnel available (1.3%) and create a specific medical report and a Primary Care notification form when dealing with cases of violence against women.

Discussion

Although violence against women is considered to be a major public health issue that has reached epidemic proportions and is a priority at an international level due to its impact both to the women who suffer from it and their surroundings, about 25.9% of health care professionals did not act when they detected such cases and 5.1% of those who answered the survey think it is not their job to do so. Earlier studies showed that violence against women increases the risk of poor health and worsens how it is seen, as well as showing that physical and psychological harm tends to appear both in the medium and long run (^{Lasheras Lozano et al., 2008}; ^{Montero et al., 2011}; ^{Polo Usaola et al., 2010}; ^{Ruiz-Jarabo Quemada & Blanco Prieto, 2004}; ^{Sanz-Barbero, Rey & Otero-García, 2014}; ^{Vives-Cases, Ruiz-Cantero, Escriba-Aguir & Miralles, 2011}). Moreover, the more intense and the longer this violence is suffered, the worse these symptoms are (^{Gutmanis, Beynon, Tutty, Wathen & MacMillan, 2007}). According to a study carried out by the Community of Madrid, out of the women that have suffered injuries due to this type of violence, 12.6% received medical care at the emergency room and refer to a higher morbidity and therefore higher usage of the health care resources (^{Lasheras Lozano et al., 2008}; ^{Montero et al., 2011}; ^{Vives-Cases et al., 2011}).

In spite of the consequences that this issue has for the health care system, currently 79.8% of health care professionals have not been trained and, according to our study, those who were had therefore a wider knowledge on the topic. This result is similar to previous studies, in which out of all the respondents, 71.74% of them did not received any training on gender-based violence and 89.67% considered this training to be necessary (^{Carmona Franco & Pou Navarro, 2010}; ^{Coll-Vinent et al., 2008}, p.; ^{Elliott, Nerney, Jones & Friedmann, 2002}; ^{Ferrer Pérez, Bosch Fiol & Ramis Palmer, 2008}; ^{García Torrecillas, Torío Durántez, Lea Pereira, García Tirado & Aguilera Tejero, 2008}). Higher levels on detecting cases of gender-based violence were shown in those health care professionals that were adequately trained, which came along their own confidence to be able to spot these type of situations (^{Coll-Vinent et al., 2008}, p.; ^{Elliott et al., 2002}; ^{Ferrer Pérez et al., 2008}; ^{García Torrecillas et al., 2008}). According to the 98.7% of the respondents, gender-based violence goes unnoticed, as shown in previous studies (^{Arredondo Provecho et al., 2012}, 2008; ^{Pueyo, 2002}; ^{Rodríguez-Bolaños et al., 2005}; ^{Valdés Sánchez et al., 2016}).

Healthcare professionals are becoming more aware of the importance of how they procedure when facing cases of violence against women and the pertinence of coordination with other professionals to treat these cases in an interdisciplinary way. The work for this professionals is less defined by stereotypes and they have more resources available to take action, but there is a need to spread action protocols so all health care professionals can apply them when assisting in these cases.

Moreover, health care professionals also claim that training is key to act adequately. Therefore, there is a need to keep creating continued training programs on specialised care for the surveyed professionals, as well as seminars and workshops that provide with action tools previously agreed by management on each health care centre. These action tools could be implemented through practical sessions using simulation to encourage joint work amongst all health care professionals involved in assisting women who suffer this type of violence. Through a collaborative training perspective, an interdisciplinary point of view on the matter would be fostered to improve overall coordination when treating these cases. In fact, the health sector is ideal to contribute to prevention given its characteristic cross-sectional collaboration (^{Dirección General de la Mujer - Spain, 2016}; ^{Michau, Horn, Bank, Dutt & Zimmerman, 2015}).

The Estrategia madrileña contra la violencia de género (2016-2021) (Madrid Framework against Gender-Based Violence) provides both training and implementing research initiatives to reinforce the Red de Atención Integral para la Violencia de Género de la Comunidad de Madrid (^{Dirección General de la Mujer, 2016}) (Comprehensive Care Program towards victims of Gender-Based Violence of the Community of Madrid), which the main goal of offering an specific health response to each woman. This should be included in the study plan in Nursing, Medicine, Social Worker, Law and Psychology studies at a university level, and also implemented in the induction programs for new hospital workers and medical residents.

There is a need to spread the tools created to fight against this type of violence, both within the community and the hospital that took part in this survey, in order to unify how to act at a health-care level and to guarantee that all those women who suffer violence have access to comprehensive care. Improve coordination is key to not re-victimize these patients.

Health care professionals and the overall society need to change their attitude towards this issue, that has an evitable loss of human lives and an incalculable cost. There is also a need to increase investment in innovative programs, encourage collaborations between researchers from different areas and work towards a leadership on the health care sector to “achieve a higher impact in primary prevention” (^{Michau et al., 2015}). Last year, 44 lives were lost due to this type of violence and even though several initiatives have been implemented to improve the situation of all those women who suffer from it, we have to continue our work. There are new initiatives that promote interventions with men and young boys to change the perspective on masculinity that encourages violence (^{Jewkes, Flood, & Lang, 2014}).