Barriers to disclosure of violence against women in health services in Palestine: qualitative interview- based study

maggie evans (  m.a.evans@bristol.ac.uk ) University of Bristol Medical School https://orcid.org/0000-0002-2307-0584 Amira Shaheen An-najah National University Faculty of Medicine and Health Sciences gene feder University of Bristol Medical School loraine bacchus London School of Hygiene and Tropical Medicine Department of Population Health manuela colombini London School of Hygiene and Tropical Medicine Department of Population Health suzy ashkar An-najah National University Faculty of Medicine and Health Sciences abdulsalam alkaiyat An-najah National University Faculty of Medicine and Health Sciences


Abstract Background
Violence against women (VAW) damages health and requires a global public health response and engagement of clinical services. Recent surveys show that 27% of married Palestinian women experienced some form of violence from their husbands over a 12 month's period, but only 5% had sought formal help, and rarely from health services. Across the globe, barriers to disclosure of VAW have been recorded, including self-blame, fear of the consequences and lack of knowledge of services. This is the rst qualitative study to address barriers to disclosure within health services for Palestinian women.

Methods
In-depth interviews were carried out with 20 women who had experienced violence from their husbands.
They were recruited from a non-governmental organisation offering social and legal support. Interviews were recorded, transcribed and translated into English and the data were analysed thematically.

Results
Women encountered barriers at individual, health care service and societal levels. Lack of knowledge of available services, concern about the health care primary focus on physical issues, lack of privacy in health consultations, lack of trust in con dentiality, fear of being labelled 'mentally ill' and losing access to their children were all highlighted. Women wished for health professionals to take the initiative in enquiring about VAW. Wider issues concerned women's social and economic dependency on their husbands which led to fears about transgressing social and cultural norms by speaking out. Women feared being blamed and ostracised by family members and others, or experiencing an escalation of violence.

Conclusions
Palestinian women's agency to be proactive in help-seeking for VAW is clearly limited. Our ndings can inform training of health professionals in Palestine to address these barriers, to increase awareness of the link between VAW and many common presentations such as depression, to ask sensitively about VAW in private, reassure women about con dentiality, and increase awareness among women of the role that health services can play in VAW.

Background
Violence against women (VAW) damages health, requiring a public health response and engagement of clinical services. It is estimated that 3% of women globally have experienced physical and/or sexual violence from a partner during their lifetime (1). This prevalence is raised to 37% in Eastern Mediterranean countries (1) (2). A recent systematic review showed that a doubling of this lifetime prevalence (70%) was reported among Arab women attending health care settings in Arab countries (3).
Looking speci cally at Palestine, a 2019 survey by the Palestinian Centre Bureau of Statistics (PCBS) found that 27% of currently married or ever married Palestinian women had at least one experience of some form of violence from their husbands in the 12 months preceding the interview (4). Psychological violence was the highest at 52%, economic 41%, social 33%, physical 17%, and sexual 7%. Sixty-one per cent of interviewed survivors had not disclosed violence either formally or informally. 24% of survivors took refuge on their parents' or siblings' homes and a further 20% did not leave their homes, but asked for help from either their parent or relative (4). Six per cent sought advice from a work colleague or a neighbour. Despite 40% of interviewed survivors reporting that they were aware of the existence of support services, only 5% had sought formal help, generally from the police or legal services (4).
The above gures make no reference to help-seeking via health services, despite the serious health consequences of VAW such as depression, sleep problems, abortion, pain, and hypertension (4),(5),(6),(7), (8), (9). VAW results in substantial social and economic costs related to treating the physical and psychological impacts on women, absence from work, reduced quality of life, and problems with integrating into society (10) (11). Eliminating VAW by 2030 is the second item of the UN 5th Sustainable Development Goals (SDGs), which would make a major contribution to women's health (12).
Health services could potentially play an important role in supporting women who are experiencing violence (13). This can be done within the clinical setting and through referral of identi ed women to specialist services (14). However, studies in the UK, India and Malaysia reveal that women experience barriers to help-seeking and disclosure of violence in the clinical setting. Barriers include self-blame, shame and embarrassment, prior negative experiences of help-seeking, fear of the consequences of disclosure, economic dependency on the perpetrator and lack of awareness about formal support services related to VAW (15)(16) (17). Similar barriers were identi ed among women from eastern Mediterranean countries (18).
Studies show that women who have experienced VAW are more likely to disclose to a health care provider if asked in an empathic, non-judgemental way (19). Little is known about how Palestinian women view the role of health professionals in responding to VAW, or how they feel about disclosing their experience of violence in health care settings. The study reported here aimed to articulate Palestinian survivors' of VAW attitudes towards and experiences of disclosure in a health setting. It is the rst qualitative study to explore barriers to disclosure of VAW among Palestinian women survivors of violence.

Methods
As a part of a larger mixed-method study aimed at enhancing the Palestinian primary health care response to VAW, we conducted 20 semi-structured interviews with Palestinian women survivors of violence. This article presents results from the qualitative interviews.
Recruitment and sample Women who had experienced violence were recruited from a non-governmental organization (NGO) that provides legal and social support services, free of charge, to survivors of domestic violence. A convenience sample of 20 women aged 18 and over, who had experienced domestic violence, were interviewed in Ramallah and Hebron in July through August 2017. The NGO contacted twenty women and explained the study to them. All the contacted women agreed to participate.

Interview Procedure
After written informed consent, women were interviewed by one of two female researchers in a private room provided by the NGO. All women were given transport costs to attend the interview. Semi-structured interviews, using a piloted topic guide, were conducted to explore women's personal experiences with violence, in uences on their decisions to disclose violence, and their experience of talking to health care providers (HCPs) about violence and abuse. Further information about the topics covered in the interview is given in the Topic Guide: [see Additional le 1]. Interviews were conducted in Arabic and lasted for 1 to 2 hours. A social worker was available on site for any women in need of support during or after the interview.

Qualitative Analysis
Interviews were audio-recorded and were translated and transcribed verbatim into English. A sample of the transcribed interviews was checked against the Arabic recording, by the rst author, to ensure accuracy. Data from transcripts were anonymised and analysed thematically following the method developed by Clarke and Braun (20). A coding framework was developed by ME, SA and AS and a sample of transcripts were double coded for veri cation. NVIVO 11 was used to facilitate the initial coding and analyses. Emerging themes were identi ed and discussed by ME, SA and AS.

Characteristics of participants
Most of the women were in marriages arranged by their families and the majority were separated or divorced. The husband was identi ed as the main perpetrator by all the interviewed women. Three women also identi ed in-laws as secondary perpetrators. Further details are given in Table 1. Barriers to survivors disclosing VAW to health care providers Eleven out of the twenty interviewed survivors said that they had disclosed violence to HCPs at some point. However, all the women encountered multiple barriers to talking to HCPs about their experiences that either prevented disclosure or made it di cult. Themes were identi ed by the authors that re ect the cultural barriers to talking about VAW that pervade all areas of women's lives and experiences.

Survivors' individual level barriers
Two key individual barriers that were identi ed were women's sense of dependence on their husband and their fear of the consequences of disclosure.
Dependence on their husband Others, however, said they would prefer HCPs to look beyond their physical health, show concern for women's psychological well-being and take the initiative to ask about violence.
"maybe they could ask me questions, give me support …" [24 year old woman, Hebron].
"Well, women feel that they don't care. I don't feel like they care about these things at all. So at least they should ask those that he feels something might be wrong." [23 year old woman, Hebron].
Most women were clear that the initiative must come from the HCP asking direct questions, even repeatedly, in order to overcome their initial reluctance to disclose. Women's direct experiences of disclosure and nondisclosure to HCPs Missed opportunities for disclosure were described by women who presented with warning signs of abuse including low mood, bruising and poor nourishment, with no questions asked by HCPs.
"There was an apparent thing on my arm, it was obvious that I had. When I get upset it's obvious, he didn't ask me about it or anything" [30 year old woman, Hebron].
"I was crying but, its normal, no one asked me about it. About anything!" [23 year old woman, Hebron].
However, in spite of the barriers, just over half of these survivors had disclosed violence to HCPs. Many of them, however, reported little bene t. Simply initiating a conversation was felt to be insu cient, some women felt that HCPs should make a full assessment of the violence.
"What happened, why it happened. They should do a proper assessment about anything that looks like a case of abuse. It's obvious when something is normal and something is strange." [34 year old woman, Hebron].
Women often said they wanted help to change their husband's behavior, so that they could preserve their marriage, and their social and nancial survival. They did not know who to call on other than involving the police and ling a complaint. Women did not trust patient con dentiality, and were anxious about disclosing in case 'domestic violence' appeared in writing in their medical report. They described overlapping social and professional networks in their communities. HCPs may know other family members, social ties and loyalties might outweigh concepts of con dentiality, and disclosure may not remain a private matter. For women, this risked an escalation of violence and other repercussions. One woman whose husband was in prison for violence felt she was being watched by the community and always had to be on her best behavior, as if she were the guilty party. Others echoed this experience of being abandoned by society for speaking out. Fear of being blamed and being seen as a 'homewrecker' stopped some women from ling for divorce.
"I think it's more the nature of our society. Our society abandons a woman who speaks out about her circumstances, even when they are bad" [36 year old woman, Hebron].
"Like I said before they put all the blame on the woman and it's because of you, like how they've already put all the blame on me. The closest people to you; you're the reason, you're the home wrecker" [30 year old woman, Hebron].
One woman regretted not having spoken out sooner, since she now recognized how her rights had been taken away since marriage.
"no, now I would have talked. I would have talked then because I've given up so many things in my life, from the day I married [perpetrator] until now, there are a lot of rights that he's denied me from" [36 year old woman, Hebron].

Stigma
Women's fear of being stigmatized for their actions was a strong theme in their accounts. They described their fear of the stigma of a 'mental health label' or of being a 'home-wrecker', and of being ostracized by society for speaking out against their husband, separating from or divorcing him. After leaving a violent relationship, women continued to feel stigmatized and faced barriers to getting support for themselves or their children, such as attending counselling sessions alone or getting psychological help for themselves or their children.
"Even for my son and his sessions, in the beginning I told her even if you need to put two sessions a week, do it. I wanted my son to get better, but I felt that it was unaccepted" [45 year old woman, Hebron].

Discussion
The recognition that women face multiple barriers to disclosure of abuse at all levels of their personal, social and cultural life echoes Heise's ecological model of the multiple levels of in uence on the perpetration of abuse. Integrating results from international and cross-cultural research, Heise identi ed the predictive factors of abuse as being "grounded in an interplay among personal, situational, and sociocultural factors" (21). This study shows that the same factors that render women vulnerable to abuse are also limiting their ability to seek help.
Although the majority of the women in the study had left their abusive relationship, their pathways to support had been through legal channels rather than health care. Having found freedom, some women regretted not having challenged cultural norms sooner and taken opportunities to disclose, for example when presenting to HCPs with injuries caused by violence. However, women's agency to be proactive in help-seeking or trying to change their situation, is clearly limited. Women felt disempowered in their marriages, and the only answer was for their husband's behaviour to somehow change. Meanwhile, their own actions were often tactical, motivated to ensure damage limitation for them and their children.
The context of women's lives was the largely patriarchal and hierarchical structure of the Palestinian family, with its hegemonic masculinity (22), where men expect their wives and children to respect them, and comply with their roles and demands. In this context there are many examples of the normalisation of VAW, and few opportunities are available for women to talk about VAW either in their informal networks or to professionals (23), (24). These di culties were compounded by overlapping social and professional networks and the custom of family members accompanying women to healthcare appointments, leading to a lack of trust in disclosure to HCPs and a lack of the privacy to do so. Family members, HCPs and other members of the community might all subscribe to a 'conspiracy of silence' around such uncomfortable issues. Fear of making matters worse, being subjected to even more abuse, of being ostracised by society and losing their children were all signi cant barriers to women speaking out about abuse.
Women described feelings of embarrassment and shame from disclosure, re ecting that VAW is perceived as a private issue, and that sharing experiences with others would not be accepted (25)(26). Lack of awareness of possible help that can be obtained from health care services was a further constraint on survivor disclosure. This is perhaps not surprising given the ndings of a companion study interviewing HCPs and health o cials in Palestine, carried out alongside the current study. This revealed the lack of clear VAW guidelines for HCPs, and protocols for how to respond to disclosure, which were recognized as challenges to the health service's response to VAW (27). However, all the women who were interviewed had found a way to get help from a professional agency, although the role of HCPs was limited. The determination of the women to break free meant that the majority were living apart from their perpetrator at the time of interview. In spite of the barriers highlighted in this study, a systematic review (3) suggests that Arab women still view visiting the health care setting as socially acceptable, and once trust is gained, and con dentiality is granted between them and their health care provider, disclosure will follow.
In order to decrease VAW, a focus group of young Palestinians from Gaza recommended raising awareness among Palestinian women toward their legal rights and the available services (28).
Awareness raising must, however, go alongside measures to address societal norms towards women and gender roles. Other studies also indicate the importance of awareness campaigns in introducing available services to women victims of violence and their communities in an attempt to raise the level of help seeking (23)(24).
This Palestinian study adds to the ndings of previous qualitative studies that highlight the importance of sensitivity in the timing and questioning about violence by HCPs, who must be alert to windows of opportunity. A conceptual framework for understanding the processes of help-seeking among survivors of intimate partner violence, taking into account individual, interpersonal, and sociocultural factors was developed by Liang et al (29). This work was developed in further studies that stress the importance of a woman's personal 'readiness' to disclose VAW, at a time that is right for her (30)(31). The health system itself must also be 'ready' to take on responsibility for helping women survivors of VAW, with suitable infrastructure, training and referral pathways. A recent study in Lower and Middle Income countries (LMIC) explores the concept of health systems 'readiness' and corroborates many of the ndings in the present study as regards health service barriers to disclosure (27).
The role of health care systems in responding to violence against women and in facilitating access to support services has been demonstrated worldwide (19). Our ndings can inform training of HCPs in Palestine to facilitate asking about VAW and responding appropriately.

Strengths and Limitations
This is the rst study to investigate barriers to the disclosure of violence among Palestinian women exposed to VAW. The use of thematic analysis that starts with coding, grouping of codes under speci ed themes, investigating and de ning these themes by more than one researcher, gives an in-depth view of the survivor experience that re ects on their collective experience rather than an individual one. Data for this study were collected by interviewing women in two legal centres, who had successfully sought help, hence the results might not re ect all the barriers that are experienced by women. Women who visited these legal centres may have been more severely affected by violence. As the recruitment of participants were at voluntary basis, it is possible that those who agreed to be interviewed were the more comfortable with the topic being investigated, or that those who refused to participate were more severely affected and scared.

Conclusions
Training of Palestinians HCPs on response to VAW should be tailored to address the barriers to disclosure experienced by survivors, for example, how to ask sensitively about VAW in private, the importance of reassuring women about con dentiality, and increasing awareness of the link between VAW and many common presentations such as depression. Actions such as securing private spaces in clinics, for women to feel safe to disclose, and increasing awareness among women of the role that health services can play in VAW is crucial.