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Gaceta Sanitaria

versión impresa ISSN 0213-9111

Gac Sanit vol.28 no.3 Barcelona may./jun. 2014 



Applying the WHO recommendations on health-sector response to violence against women to assess the Spanish health system. A mixed methods approach

La aplicación de las recomendaciones de la OMS sobre la respuesta del sector salud a la violencia contra las mujeres para evaluar el sistema sanitario español



Isabel Goicoleaa, b, Carmen Vives-Casesb, c, Fauhn Minvielle, Erica Briones-Vozmedianob y Ann Öhmana, d

a Unit of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
b Public Health Research Group, Department of Community Nursing, Preventive Medicine and Public Health and History of Science, Alicante University, Alicante, Spain
c CIBER of Epidemiology and Public Health (CIBERESP), Barcelona, Spain
d Umeå Center for Gender Studies, Umeå University, Umeå, Sweden

This study has been funded by a COFAS grant (supported by COFUND action within the Marie Curie Action People, in the Seventh Framework programme and the Swedish Council for Working Life and Social Research/FAS-Forskningsradet för arbetsliv och socialvetenskap).





This methodological note describes the development and application of a mixed-methods protocol to assess the responsiveness of Spanish health systems to violence against women in Spain, based on the World Health Organization (WHO) recommendations.
Five areas for exploration were identified based on the WHO recommendations: policy environment, protocols, training, accountability/monitoring, and prevention/promotion. Two data collection instruments were developed to assess the situation of 17 Spanish regional health systems (RHS) with respect to these areas: 1) a set of indicators to guide a systematic review of secondary sources, and 2) an interview guide to be used with 26 key informants at the regional and national levels.
We found differences between RHSs in the five areas assessed. The progress of RHSs on the WHO recommendations was notable at the level of policies, moderate in terms of health service delivery, and very limited in terms of preventive actions. Using a mixed-methods approach was useful for triangulation and complementarity during instrument design, data collection and interpretation.

Key words: Violence. Battered women. Health policy. Health planning. Qualitative research.


Esta nota metodológica describe el desarrollo de un protocolo de investigación que utiliza métodos mixtos para evaluar la respuesta del sistema sanitario español a la violencia contra las mujeres, partiendo de las recomendaciones de la Organización Mundial de la Salud (OMS).
A partir de estas recomendaciones, se definieron cinco áreas para su evaluación: políticas, protocolos, formación, rendición de cuentas/monitoreo, y acciones de prevención y promoción. Se desarrollaron dos instrumentos - un conjunto de indicadores para orientar la revisión sistemática de fuentes secundarias, y una guía de entrevista, que se utilizó con 26 informantes clave - y se aplicaron en los 17 sistemas sanitarios autonómicos.
Se evidenciaron diferencias entre autonomías y entre las cinco áreas evaluadas: notable progreso en políticas, menos destacado en la prestación de servicios y muy limitados en acciones preventivo-promocionales. Combinar métodos permitió lograr triangulación, complementariedad y desarrollo, durante el diseño de los instrumentos, la recogida de información y su interpretación.

Palabras clave: Violencia. Mujeres maltratadas. Política de salud. Planificación en salud. Investigación cualitativa.



The health sector plays an important role as part of an integrated response to violence against women (VAW).1 Women access health services more often than other public services, and proper training of health providers on VAW improves referral to specialist VAW services2 - where intensive advocacy interventions can be provided.3

Despite widespread recognition of the importance of the health sector in addressing VAW, there is little published research on how and to what extent regional or national health systems manage this issue.4 Despite the fact that methods exist to assess the responsiveness of providers and health facilities to VAW, there are few methodologies that assess responsiveness of entire health systems.4

This methodological note describes the development and application of a mixed methods approach to assess the responsiveness of Spanish health systems to VAW, based on the World Health Organization (WHO) recommendations.5


Applying the WHO recommendations to develop a research protocol

The WHO recommendations emerged from a 2009 expert meeting to develop guidelines for the health sector response to VAW. Experts from 20 countries attended, as did the Reproductive Health and Injury Prevention departments of WHO. Thirteen key elements were identified: 1) enabling environments, 2) training, 3) systems and services, 4) accountability and monitoring, 5) research and surveillance, 6) approaches to psychosocial support, 7) non-negotiable principles, 8) screening, 9) network development, 10) linking VAW with child protection, 11) mandatory reporting (straightforward regarding the importance of ensuring confidentiality and safety, and ambiguous regarding reporting without women's consent, 12) responding to men as victims and perpetrators, and 13) prevention and promotion.5

For this study, the 13 themes were adapted into five key areas: 1) enabling policy environment and networks, 2) protocols and guidelines for the healthcare response, 3) training of health professionals, 4) accountability and monitoring mechanisms, and 5) prevention and promotion.

The five areas and selected indicators are shown in Table 1.

For each of these areas, two data collection instruments were developed: 1) a set of indicators, to guide the systematic review of secondary sources, and 2) an interview guide, to be used during semi-structured interviews with key informants (Appendix A).


The setting

Spain's Gender Violence Law of 2004 strengthened the role of health services regarding VAW: possible cases should be identified, managed, and addressed through a multidisciplinary response.6 The National Commission Against Gender-Based Violence (NCAGBV) was created within the Inter-territorial Council of the National Health System. Three actions are indicated to facilitate integration of VAW nationally and within the autonomous regional health systems (RHSs): 1) development of protocols, 2) training of health professionals, and 3) development of information systems- based on 11 national common indicators for monitoring VAW cases detected within health facilities. At the regional level, delegates to the NCAGBV and civil servants are responsible for the coordination of these actions.

We included 17 Spanish RHSs in this study; the autonomous regions of Ceuta and Melilla were excluded.


Using mixed-methods to refine the protocol instruments and collect information

According to Johnson et al. a mixed methods research approach is useful for triangulation, complementarity, development, initiation and expansion.7

Data collected through individual interviews served to triangulate and complement the information gathered through the documentary review. Mixed methods were useful for developing the data collection instruments. Information from the interviews facilitated further development of the indicators to be assessed, while data collected through documentary review served to further develop the interview guides.

Content analysis of secondary sources

Secondary sources were systematically reviewed through content analysis to assess each indicator for each of the 17 RHSs. Regional documents reviewed included VAW laws and health plans and protocols, and national documents included the Ministry of Health Gender Violence Reports for the years 2005-2011. Documents were retrieved through the internet, focusing mainly on official health-related websites of the autonomous regions and the NCAGBV. Hard copies of certain documents (i.e. training programs) were collected and revised. For each RHS, indicators were assessed as present or absent.

Interviews with key informants

Individual interviews were conducted with 26 key informants: 23 from the 17 RHSs and 3 at the national level. Informants in the autonomous regions were civil servants of the RHSs in charge of coordinating the health-sector response to VAW. One key-informant per autonomous region was contacted first. In some regions another informant was suggested due to his/her experience in certain areas of interest to the study. Informants at the national level were representatives of the Observatory of Women's Health and academic institutions. They were all participants in working groups on VAW and some of them had also participated in the NCAGBV. They were chosen based on their status as privileged informants - able to contribute significantly to our research- through theoretical sampling. Fifteen of the interviews were conducted face to face, 11 were phone interviews, and the average duration was one hour.

Interviews were semi-structured and followed a guide. As unexpected issues emerged they were explored in subsequent interviews following an emergent design.8 Verbatim transcripts were analyzed using qualitative content analysis, focusing on the manifest content.9

The study was approved by the Ethical Committee of the University of Alicante. Written informed consent was obtained from each participant before interviews were conducted. Information that could identify the respondents was excluded.


Preliminary findings from the application of the methodology

The methodology mapped differences between RHSs, in terms of documentation and levels of achievement in the five assessed areas. Progress was notable at the level of policies and protocols, moderate at the level of health service delivery, and very limited in terms of the institutionalization of action on prevention and promotion. A summary of findings is presented in Table 2.



This study is the first attempt to translate WHO recommendations on the health sector response to VAW into a protocol to assess health system responsiveness to VAW. It should be noted that the latest WHO guidelines (outlined in the document "Responding to intimate partner violence and sexual violence against women"10) were not available at the time of this study, therefore the WHO Expert Meeting on Health Sector Responses to VAW was used as a guide. Our subsequent review of the new guidelines shows general alignment with the fields assessed and indicators used in our study.

Using a mixed methods approach was useful for the development of instruments, data collection and interpretation of results. The documentary review offered interesting information on differences among RHSs, but left important issues un-informed, for example, processes and quality monitoring, and aspects of prevention and promotion. Information collected through the interviews allowed us to put information into context and understand differences between RHSs in each of the five areas. It should be noted that there could be differences in the information collected by phone as compared to face-to-face. However, both phone and face-to-face interviews covered the same aspects and had similar durations.

This methodology was applied to the Spanish context, but it could be used to assess health system responsiveness in other settings as it permits detecting differences between health systems and conducting in-depth analysis, and because it is grounded in international standards.


Editor in charge of the article

Glòria Pérez.


Contributions of authorship

Isabel Goicolea conceived and designed the study, participated in data collection, analysis and interpretation, wrote the first draft of the paper and subsequent revisions and approved the final version.

Carmen Vives Cases and Ann Öhman participated in the design of the study, and the interpretation of the data, critically reviewed drafts of the paper and approved its final version.

Fauhn Minvielle and Erica Briones-Vozmediano participated in data collections, analysis and interpretation, critically reviewed drafts of the paper and approved its final version.


Conflicts of interest

The second author belongs to the current editorial committee of Gaceta Sanitaria.



The authors are grateful to the Observatory of Women's Health of the Spanish Ministry of Health for facilitating access to relevant information and contacts, and to the Public Health Research Group of the Department of Community Nursing, Preventive Medicine and Public Health and History of Science of the Alicante of University (Spain), especially to Gaby Ortiz and Jordi Torrubiano for their support and feedback during the development of the study protocol. The authors are particularly grateful to Asunción Cisneros, Mari Luz Lou, Borja Rodriguez-Maribona, Alejandra Carmona, Rosa del Valle, Carmen Fernandez, Maria José López, Marisa Pires, Marina Tourné, and all the participants in the 17 autonomous regions and at the national level who shared their time, enthusiasm, experiences and expertise, and facilitated access to unpublished documents and information.


Appendix A. Suplementary data

Supplementary data associated with this article can be found, in the online version, at



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E-mail address: (I. Goicolea).

Received May 15, 2013
Accepted August 5, 2013

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