doi: 10.1111/hex.12283
Barriers and facilitators to effective coverage of Intimate Partner Violence services for immigrant women in Spain Erica Briones-Vozmediano PhD,* Daniel La Parra PhD†‡ and Carmen Vives-Cases PhD MPh‡§ *Research Assistant, §Senior Lecturer, Public Health Research Group, University of Alicante (Alicante), Spain, †Senior Lecturer, Department of Sociology II, University of Alicante (Alicante), Spain, ‡Senior Lecturer, Interuniversity Institute for Social Development and Peace, WHO Collaborating Centre for Health and Social Inclusion (Alicante), Spain and §Senior Lecturer, Epidemiology and Public Health CIBER (CIBERESP), Barcelona, Spain
Abstract Correspondence Erica Briones Vozmediano Research Assistant Department of Community Nursing Preventive Medicine & Public Health and History of Science University of Alicante San Vicente del Raspeig P O Box 99 E-03080 Alicante Spain E-mail: [email protected] Accepted for publication 16 September 2014 Keywords: access and evaluation, battered women, emigrants and immigrants, health-care disparities, Spain, women’s health service
Objective To explore service providers’ perceptions in order to identify barriers and facilitators to effective coverage of Intimate Partner Violence (IPV) services for immigrant women in Spain, according to the different categories proposed in Tanahashi’s model of effective coverage. Methods A qualitative study based on 29 in-depth personal interviews and four group interviews with a total of 43 professionals working in public services (social and health-care services, women’s refuges, the police force, the judiciary) and NGOs in Barcelona, Madrid, Valencia and Alicante (Spain) in 2011. Findings Current IPV services in Spain partially fail in their coverage of abused immigrant women due to barriers of (i) availability, such as the inexistence of culturally appropriate services; (ii) accessibility, as having a residence permit is a prerequisite for women’s access to different services and rights; (iii) acceptability, such as women’s lack of confidence in the effectiveness of services; and (iv) effectiveness, for example, lack of specific training among professionals on the issues of IPV and immigration. However, interviewees also identified facilitators, such as the enabling environment promoted by the Spanish Law on Gender-Based Violence (1/2004), and the impetus it has provided for the development of other specific legislative tools to address IPV in immigrant populations in Spain (availability, accessibility and effectiveness). Conclusion Whilst not dismissing cultural barriers, aspects related to service structure are identified by providers as the main barriers and facilitators to immigrant women use of IPV services. Despite noteworthy achievements, improvements are still required in terms of mainstreaming assistance tailored to immigrant women’s needs in IPV policies and services.
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Introduction Violence against women (VAW) is an extreme manifestation of gender inequality in society and a serious violation of fundamental human rights. The United Nations declaration on the Elimination of VAW defined it 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 acts such as coercion or arbitrary deprivation of liberty, whether occurring in public or private life.1 Intimate Partner Violence (IPV) against women is the most common type of male VAW. According to a recent WHO report on worldwide lifetime IPV prevalence rates, at least 30% of ever-partnered women have been abused by their male partner.2 Although IPV against women occurs without exception in all countries, all cultures and at every level of society, it may vary dramatically both between and within countries.3 There are cases such as Ethiopia, with a lifetime IPV prevalence of 70% and others such as Japan, with a prevalence rate of 15%.3 Within countries, some populations of women may be at greater risk. In Spain, a cross-sectional study of 10 202 women attending primary health-care centres reported an IPV prevalence rate of 27.9% in immigrants compared to 14.3% in Spanish women.4 Research has shown that immigrant women in abusive relationships have unequal access to the services provided by the host countries, due to the presence of barriers such as lack of fluency in the host country’s language, limited knowledge of available IPV-related resources and previous experiences of discrimination in their dealings with institutions and professionals.5–7 Furthermore, it has been demonstrated that this unequal access to IPV services observed between immigrants and natives interacts with other barriers, such as restricted opportunities to find decent employment or an income which would provide women with financial independence from their partners, length of residence in the host country and legal (or illegal) status.8–12
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Some governments are aware of these difficulties and have legislated to provide special protection measures for immigrant women and their children in abusive relationships, such as facilitating the process of achieving legal status in the host country.13 Spain is a noteworthy example of this, with policies aimed at facilitating access to social, health and legal services for abused immigrant women and providing the possibility of obtaining temporary residence and work permits.14–16 Despite these supportive policies, of the 62 deaths from IPV recorded in 2011, 35% were immigrant women; in the same year, 36% of the women who filed complaints against their aggressors in the courts or at the police station were immigrants, of whom 41% subsequently withdrew their complaint.17 In Spain, officially reporting a case of IPV is the only mean to access to public supporting resources for battered women.18 In his study entitled ‘Health Service Coverage and its evaluation’,19 Tanahashi proposed a model in which ‘health service coverage is considered as a concept expressing the extent of interaction between the service and the people for whom it is intended, this interaction not being limited to a particular aspect of service provision but ranging over the whole process from resource allocation to achievement of the desired objective’. This process involves a variety of factors related to availability of material and human resources, accessibility, acceptability, contact and effectiveness. Studies on abused immigrant women’s access to health services have predominantly focused on characteristics related to cultural factors (acceptability) or on legal aspects (accessibility), but have minimized the role of the health services (availability, effectiveness) or the key role of the interaction between the health services and the population.20,21 In spite of the fact that it was proposed in the year 1978, its current application has advantages for explaining elements facilitating or hindering the access or give up of services, according to the different stages of the model, where specific social groups – vulnerable populations – face different barriers and they do not have contact with services.22,23
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In this study, we explored IPV service providers’ perceptions of the barriers and facilitators to effective IPV service coverage of immigrant women, according to four of the analytical categories proposed by Tanahashi: availability, accessibility, acceptability and effectiveness.
Methods Setting and approach Twenty-nine in-depth personal interviews and four group interviews (with two or five participants each, n = 14 participants) were conducted with a total of 43 professionals involved in providing support to abused immigrant women. Forty of the participants were women and three were men, and they were employed in non-governmental organizations (NGOs) and public institutions related to VAW or immigrant populations with specific VAW programmes (Table 1). These professionals came from four different cities in Spain (Barcelona, Madrid, Valencia and Alicante); those cities concentrate 46% of the migrant women population of Spain, as there are more employment opportunities.24 Barcelona and Madrid are the two biggest cities of Spain, where migrant women represent the 9.6 and 8.5, respectively, of their general population; in Alicante, they are the 8.2% and in Valencia, the 5.4%.25 Sampling and data collection Theoretical sampling was used26 according to the different professional profiles of the public institutions and NGOs capable of contributing to our research question. The first participant recruitment strategy employed was to contact a women’s refuge in Alicante. Next, we recruited professionals via a social worker, who enabled us to contact professionals working with NGOs. Recruitment of the latter informants was achieved using snowballing. The interview guide was produced after reviewing the literature and considering the experience and knowledge of the research team. There was no predetermined sequential order,
and questions were open-ended. The interview was divided into four sections, concerning their experience with abused immigrant women and the problems encountered, the interventions carried out, their perceptions regarding immigrant women’s satisfaction with these interventions and resources, and their general evaluation and the possibility of improving support to abused immigrant women (see Appendix 1). The interviews were carried out at the professionals’ places of work between September 2010 and December 2011 by members of the research team and lasted for approximately 1 h. All the interviews were conducted in Spanish, which was the mother tongue for both interviewers and participants, and continued until data saturation was achieved, that is when no new information related to the research question was being obtained.27 In keeping with the principles of the Declaration of Helsinki and the Belmont Report, written informed consent was obtained from each participant prior to data collection. Data analysis The interviews were recorded digitally and then transcribed verbatim. All data were imported into qualitative analysis software Atlas.ti-5 (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany) and then examined using thematic analysis to identify pre-defined themes across the data set.28 Specifically, we classified barriers and facilitators into four areas (availability, accessibility, acceptability and effectiveness), according to Tanahashi’s model20 (Fig. 1). Although the remaining dimension of ‘Contact’ is useful for measuring ‘contact coverage’, or proportion of people in the target population who use the service, we decided to exclude it from this study because it does not indicate specific barriers or facilitators. In addition, this dimension is defined in quantitative terms, something which cannot be quantified from interviews with professionals. Through repeated readings of the texts, the authors discussed, negotiated and redefined these pre-defined themes related to Tanahashi’s
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Services coverage for abused immigrant women, E Briones-Vozmediano et al. Table 1 Professionals interviewed (n = 43)
Place of work Social Services
Associations/ NGOs
Law/Police
Interview code
Sex
Background
Professional profile
Area of work
City
1 2 3 4 5 6 11 12
Female Female Female Female Female Male Female Female
Social educator Psychologist Psychologist Social educator Social worker Social educator Lawyer Social worker
Employment educator Psychologist Educator Child educator Social worker Health educator Director Social worker
Shelter Shelter Shelter Shelter Shelter Shelter
Alicante Alicante Alicante Alicante Alicante Alicante Alicante Alicante
24
Females
25
Female
Psychologist Director IPV specialist
28 29 30 32 7
Female Female Female Female Females
8 9 10 13 14 15 16 17 18 19 20 21 22 23 26 27 31
Female Female Female Female Female Female Female Female Female Female Female Female Male Male Female Female Females
33
Female
Psychologist Social worker Social worker and anthropologist Social worker Social worker Psychologist Psychologist Social worker Sociologist Social worker Lawyer Mediator Former IPV victims Lawyer Mediator Health worker Psychologist Lawyer Social worker Lawyer Police officer Police officer Lawyer Police officer Lawyer 2 Psychologists 3 Social workers Judge
Social worker Social worker Psychologist Coordinator Workforce entry coordinators Social worker Lawyer Lecturer Former IPV victims Lawyer Mediator Health worker Psychologist Lawyer Social worker Magistrate Police officer Police officer Lawyer Police officer Lawyer Psychologists Social worker Judge
Council equal opportunities section Community centre
Barcelona
Specialist IPV service
Barcelona
Specialist IPV service Specialist IPV service Specialist IPV service Specialist IPV service Women’s association
Madrid Madrid Madrid Barcelona Alicante
Women’s association Immigrants’ association University Women’s association Immigrants’ association Immigrants’ association Immigrants’ association Immigrants’ association Immigrants’ association Immigrants’ association Specialist IPV court Specialist IPV police unit Specialist IPV police unit Specialist IPV court Specialist IPV police unit Specialist IPV court Specialist IPV court Specialist IPV court Specialist IPV court
Alicante Alicante Alicante Alicante Alicante Valencia Valencia Alicante Alicante Alicante Alicante Alicante Alicante Alicante Alicante Alicante Madrid Madrid Barcelona
IPV, Intimate Partner Violence.
definitions, dividing each theme into barriers and facilitators. To identify these themes across the data set and make sense of the pattern of responses, we generated codes from the data which identified meaningful sentences or paragraphs, reflecting a higher level of abstraction. These codes were sorted and grouped together according to pre-defined themes. The resulting description of the themes reflects the manifest content of the text, what the providers explicitly
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expressed about the process. In order to stay closer to the text, the original Spanish version was used for coding, and translation into English only took place once themes were identified.
Results Thematic analyses of the data identified barriers and facilitators of availability, accessibility, acceptability and effectiveness (Table 2).
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Target population: abused immigrant women
Figure 1 Tanahashi’s effective coverage stages, applied to an analysis of Intimate Partner Violence (IPV) services and resources. Adapted from Tanahashi.19
Availability Barriers The majority of the barriers that service providers mentioned affect both immigrant and native abused women, such as the lack of services (i.e. women’s refuges, job placement services, lack of access to housing or services for children such as nursery school) or the lack of human and/or material resources in existing services (i.e. financial assistance for integration or number of places in women’s refuges). With particular reference to immigrant women, service providers referred to the lack of services specifically for immigrant women. Far more resources are required. You need something specific for [immigrant] women. Not just in this service, but in all basic services specified by law and so on, and maybe much more protection is needed. . . Because they are much more unprotected (Interview 12: Social Worker, Woman).
Facilitators Professionals mentioned advances resulting from the Law on Gender-Based Violence (Organic Law 1/2004), which led to other
legislative changes on IPV, such as including specific measures for immigrant women. Progress is being made, we’re moving forwards all the time, that much is clear because the law is from 2004 and before that there was nothing /. . ./. Yes, but I still think it isn’t enough. (Interview 26: Police Officer, Woman)
Other improvements cited included the existence of information services, refuges, access to housing, financial assistance (welfare benefit), help in finding employment, psychological treatment, free legal assistance, advice and support, translation services and intercultural mediation. we explain all the resources available to them, the help they can get so that they know they can escape from the situation, that they don’t need to stay there because there are a lot of resources that they can use and take advantage of. (Interview 2: Psychologist, Woman)
Accessibility Barriers The main barrier for some immigrant women described by professionals is the lack of a
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Services coverage for abused immigrant women, E Briones-Vozmediano et al. Table 2 Barriers and Facilitators identified by different professionals from Intimate Partner Violence (IPV) services and NonGovernmental Organisations in Spain, 2011 Theme
Types of barrier
N professionals
Types of facilitator
N professionals
Availability
Lack of specific services and service resources
19
10
Accessibility
Requirement for regularised status Requirement to file a complaint Other requirements: administrative procedures Fear and vulnerability Fear of losing papers Fear of the aggressor Fear of the consequences of filing a complaint Lack of confidence in services Perceived disadvantage Lack of awareness Lack of training Lack of specific protocol Problems after filing a complaint Lack of coordination
21
Laws Support resources to escape from situations of violence Free provision
Acceptability
Effectiveness
18
Universal coverage Filing a complaint Linguistic proximity 32
Professional work Group interventions Information
12
18
Legislative progress Personal involvement Specific Resources
18
residence permit, as access to resources such as financial assistance, training courses to improve employability or free legal aid and defence is limited to women with a residence permit.
bureaucracy and they don’t manage to. . . (Interview 33: Judge, Woman)
Under the present Immigration Law, abused immigrant women who are in an irregular situation are entitled to a residence permit if they file an official complaint; however, administrative procedures are lengthy and complicated.
Furthermore, women may have to travel or even pay for documents from the country of origin, because the system does not assume all the costs. Providers claimed that these administrative delays complicate their interventions with immigrant women, because access to many of the available resources is dependent on possession of a residence permit, for example, help with job-seeking. For some immigrant women, another accessibility barrier mentioned is the requirement to file a complaint to acquire a residence permit or to access IPV services (according to the law, women must be granted a protection order before they are entitled to access to a refuge).
The so-called financial assistance is very limited, it’s very difficult to obtain, it requires a lot of paperwork, and these women don’t usually have the ability to apply for all of that, to endure it all, it’s very complicated, there’s a lot of
It’s a crying shame that in order to obtain emergency help you have to file a complaint, or that to be entitled to a series of employment rights you have to have a judgment or a protection order; it’s a pity because not everything works or
For a lot of women, not having the necessary papers prevents them from being independent. They can’t take courses, they can’t look for work, and we’ve found that they’re not even eligible for social services here. If they haven’t got papers, there’s a huge rigmarole entailed in obtaining a health insurance card. . ., that’s a problem that for me represents a very important barrier. (Interview 6: Health Educator, Man)
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This is especially the case for those women with a family residence permit, because they do not want their husbands to lose their permits or to endanger the family finances. In addition, lodging a complaint involves several risks for immigrant women if their complaint cannot be proven due to lack of evidence, such as losing their temporary residence permit. How many are there, how many, how many don’t we know about because they’re frightened of filing a complaint, because if then it’s proven false, they deport you, eh? That’s one of the hardest decisions for women to make, especially because so many don’t have papers and they can’t, they don’t seek help, they stay, they stay chained to the abuser. (Interview 7: NGO Professionals, Women)
Facilitators The facilitators to access to services identified by professionals included their free provision, when the economic costs are borne by the system, When they file a complaint, they are informed of their right to assistance from a lawyer specialising in gender-based violence. The first consultation is free, and after that it will depend on their income as to whether it remains free or not. (Interview 21: Police Officer, Woman)
the possibility of obtaining residence and work permits on establishing their status as women victims of IPV (through filing a complaint) We help any woman at risk of social exclusion, irrespective of whether she has papers or not, whether she’s from Spain or elsewhere. /. . ./ We don’t even ask if she’s registered with her local council, or where she lives, none of that. Any woman who’s at risk, who’s in a situation that means she needs help, must be helped. (Interview 8: Social Worker, Woman) In the case of a victim of gender-based violence, if she files a complaint this serves to regularize her situation. (Interview 26: Police Officer, Woman)
and, in the case of Latin American immigrant women, their linguistic proximity, which favours communication with professionals and increases these women’s confidence in the services and in the professionals themselves. One of the elements which is a greater facilitator for Latin American than other immigrant women is the language (Interview 24- Psychologist and Social Worker, Woman)
Acceptability Barriers The main acceptability barrier was described by professionals as being the fear experienced by immigrant women. They not only fear the offender, but also the socio-economic, legal or administrative status consequences for themselves and/or their children after initiating a legal process by filing an IPV complaint. Not being near their family, fear of deportation, the fear is always there, then there’s the fear that the aggressor will threaten to take their children away and take them off to his country, /. . ./ Clearly, all this makes immigrant women much more vulnerable. Even if you tell an immigrant woman without papers that they give you a residence permit for gender-based violence, there’s always that fear. Then there’s the economic level, because they [the aggressors] use this to intimidate the women: Look at you, you haven’t got any money, they’ll take the children off you!. . . How can you have the children if you haven’t got any money? (Interview 12: Social Worker, Woman) Retaliation, fear of retaliation, fear of failure, fear of what people will say, fear, fear and more fear means that, well, most of them take a long time to file a complaint. (Interview 10: Mediator, Woman)
Providers claimed that due to negative experiences of IPV services in the past, some immigrant women now lacked confidence in their effectiveness. In this respect, for example, some professionals mentioned the difficulties involved in living in women’s refuges.
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Services coverage for abused immigrant women, E Briones-Vozmediano et al. And because they get sent to a women’s refuge, which is often another battle Refuges aren’t easy places to be /. . ./ Living in a house where you don’t know anyone and you’re not interested in living with these people, each with their own problems. (Interview 7: NGO Professionals, Women)
In addition, professionals noted that immigrant women subjectively feel that as foreigners, they do not have the same rights as native women (i.e. in the judicial system or as regards police protection and social services), and that this is linked to their feeling of being discriminated against, not only in terms of services, but by society as a whole (in the street, in employment, etc.). They don’t feel they belong, they feel like they are going to get less response because of not being from here, they feel inferior. /. . ./ Because they’re not from here, they don’t feel like they have the same rights, so they don’t take this step with the same confidence as a Spanish woman might have. . . (Interview 13: Victim Association Group, Women)
Facilitators The professionals emphasized that it was part of their job to reduce acceptability barriers when immigrant women used IPV services. This they did by fostering trust, giving information about the existence and characteristics of the different services and providing guidance. As far as possible, we try to tell them about all the measures, to encourage them in every way possible, to get them to talk honestly with us and to tell us what happened, to open up, in the sense of telling us everything, of not leaving anything out, that we are there to help them, that this is something that they don’t have to put up with, that it’s normal to report it, I mean we do absolutely everything possible to get them to tell us what happened. (Interview 22: Police Officer, Man)
They also organized information dissemination activities and group workshops, which helped raise awareness about violence and the services available to tackle it. This programme takes into account that when a woman comes from a situation of violence she
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hasn’t got any resources, she hasn’t got a social network, she doesn’t know where to go. So the programme gets to work on that part with them, to work on all these aspects to improve their possibilities. For example, the self-esteem workshop focuses on getting them to take an active role, to take personal decisions, to develop and to receive training. (Interview 7: NGO Professionals, Women)
Providers believed that acculturation processes (understood as assimilation of the target culture) can lead to a break with immigrant women’s own cultural patterns, which may have served to legitimize violence (especially with reference to patriarchy). It is considered an offence here, whereas it may not be in their country of origin. Over there, they wouldn’t have dreamt of reporting it, but when they file a complaint here they admit that they received far more abuse in their own country than they do here, but that it was seen as normal over there, and it’s only once they’re here that they begin to think about, and not only think about, but also go about seeking help, or getting out of the situation, something which was unthinkable there (Interview 31: Social workers and psychologists, Women).
Effectiveness Barriers In general, professionals complained of a lack of specific training in and awareness about IPV and immigration in their sectors. For psychologists, it is difficult to conduct therapy with women through an interpreter, who may not be sensitive about IPV, where this option is available. There’s still a lack of awareness in many courts /. . ./ I’m sick of seeing lawyers who are on immigration duty and haven’t got a clue, and I’m sick of seeing lawyers who are involved in the issue of violence and don’t understand gender-based violence, don’t understand the first thing about it. (Interview 28: Lawyer, Woman) Often, professionals haven’t received sufficient training /. . ./. Nobody’s been trained, not in the courts, not. . . I think the first thing they should do is to teach professionals how to deal with this
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we do not adopt a series of economic measures for her: we leave her totally defenseless. . . (Interview 27: Lawyer, Woman)
A barrier to the effectiveness of resources identified by providers consisted of a lack of specific measures which meet the needs of immigrant women, such as rapid processing of work and residence permits. The additional difficulties faced by some immigrant women, such as lack of social support or economic resources, imply greater obstacles to their empowerment through access to employment and housing.
Facilitators The professionals highlighted the change brought about by the Law on Gender-Based Violence (Organic Law 1/2004), which compensates irregular status, or the development of specific services to meet the needs of immigrant women (i.e. intercultural mediation, immigrant or pro-immigrant associations, or specific training for professionals).
Within what is the present protocol, there should be something for women who require more specific, personalised treatment. (Interview 6: Health Educator, Man)
The law reform already specifically provides women with the opportunity to obtain residence and work permits. It’s moved forwards. (Interview 14: Lawyer, Woman)
Lastly, they highlighted the fact that the need to file a complaint before access can be obtained to some services and benefits determines the ineffectiveness of other resources. Firstly, because many immigrant women fail to take this step; in fact, some professionals considered that this decision needed to be thoroughly prepared, which would imply working with them directly for some time. Right, because they tell you to file a complaint, that they’ll support you, they’ll offer you the opportunity to move on and start a new life, but then you get here and that possibility doesn’t exist. (Interview 4: Social Educator, Woman)
Secondly, the IPV resources available to women once a complaint has been filed may be somewhat limited (i.e. insufficient level of police protection, limited financial assistance and lack of help in job-seeking) or slow (such as processing of residence and work permit applications). These situations affect the effectiveness of the services and in some cases explain why a woman who has filed a complaint subsequently returns to her abusive partner. When the woman files a complaint, on the one hand we do protect her and we tell her that the aggressor must keep his distance, but then we leave her without an income, without the least provision for use and enjoyment of housing and
A woman has the right to be helped in her own language, a woman expresses herself in the language she knows, we have interpretation services. (Interview 32: Psychologist, Woman)
Providers also highlighted their work as a means to increase the effectiveness of resources. They emphasized the need for personal involvement to alleviate some of the weaknesses of the system mentioned above, for example by studying the languages of the women they serve, helping them to get job interviews or simply investing more time to ensure empathic communication with these women. Luckily, most of the people who work here put a lot into it, a lot of their inner self, I mean, this isn’t an NGO but it forces you, you can’t just leave a woman like that and sometimes you do what you have to and more. (Interview 27: Lawyer, Woman)
Discussion The results of this study indicate that there are considerable barriers in Spanish IPV services to the provision of assistance for immigrant women. These are related to (i) availability, such as insufficient human and economic resources in some services and benefits, and the
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lack of culturally appropriate services; (ii) accessibility, particularly in the case of immigrant women without a residence permit, which is required to access some services and benefits, but also due to aspects such as economic barriers to some procedures and services, and geographical distance; (iii) acceptability of the services, as a result of aspects such as cultural distance or lack of confidence in IPV services; and (iv) effectiveness, given the problems that have been detected as regards coordination between services or in relation to a lack of training among professionals in how to provide effective assistance to immigrant women. Facilitating factors included the major impetus provided by the Law on GenderBased Violence (Organic Law 1/2004), which increased the provision of IPV services not only for immigrants but also for the entire population. Specifically, with regard to the immigrant population, the 2009 reform of the immigration act has also been important, because it entitles immigrant women who file a complaint about a situation of violence to access a series of services and to regularize their legal status. Indeed, filing a complaint is the principle means in Spain for women victims of IPV to obtain assistance and protection measures, whether they are immigrant or not.18,29,30 For this reason, the main barriers mentioned by professionals to access to IPV services are related to the prior step required to access these services, that is barriers to filing a complaint.12,30–34 Despite there are some crosscutting issues (such as complaints and immigrant status), each specific barrier and facilitator fit into Tanahashi’s framework in one dimension exclusively. On the one hand, each step to fill a complaint constructs a different barrier: for example, the doubts before taking the decision, the fear of the consequences (for the aggressor and for themselves) of filling the complaint or following the process activated by the official complaint. On the other hand, economic resources could be a barrier to: travel to the required places to inform themselves, to fill a complaint and to follow the process; and for taking the decision
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of leaving the aggressor (if women are not economically independent). The main limitation of this study has been the decision to use an indirect strategy to study barriers to immigrant women’s access to IPV services, consulting professional service providers rather than talking directly to immigrant women who are victims of violence. In part, the barriers identified in this study correspond to those reported by the immigrant population in other studies.30,35–39 However, there is a tendency to focus on what could be called a cultural or socioeconomic ‘deficit’, locating the main barriers in areas such as language or communication, the cultural distance with IPV services, psychosocial determinants or problems related to immigration status (lack of documentation, poverty, lack of social support, etc.).12,40–44 Focusing on the perspective of professionals has yielded information with which to address questions related to aspects such as service organization or resources, or the training received by professional teams.5,8–12,44,45 As an important next step, further research should include interviews with immigrant women to test whether these are consistent with the service providers’ views. On the other hand, the majority of interviewees were women because most of the people working in IPV services are women, a circumstance which can be considered a facilitator in terms of acceptability as it inspires trust among some groups of immigrant women such as Muslim women.12 Numerous implications for practice can be derived from the analysis presented here, such as the importance of institutional strategies to remove barriers to access for the immigrant population.46 To achieve this, IPV services must be culturally appropriate, and it is also necessary to improve their coordination, invest in the training of their professionals and provide them with material and human resources, among other aspects.5,29,47 An exhaustive study is required on the specific assistance needs of the immigrant population. In the case of immigrant women, in addition to improving specific services, it is also important to consider the reform of general aspects
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such as facilitating residence permit procedures, through increasing the provision of information for women and establishing links with the diplomatic services of the countries of origin (for example, to efficiently process documentation or provide transnational protection), to rethink the stance of the Law on Gender-Based Violence (e.g. designing intervention strategies which are not limited to cases where a complaint has been filed and/or to improve employment opportunities, housing or services for children).
Conclusion Whilst not dismissing cultural barriers, by focusing in this study on the views of service providers and conducting an analysis in order to identify barriers and facilitators to effective coverage according to Tanahashi’s model, we have also identified aspects related to service structure, such as organization, provision of human and material resources, level of expertise in attention to diversity, professional training, coordination between services, economic and time costs for victims, the inadequacy of some services as regards addressing the specific needs of users, administrative difficulties and problems encountered by institutions in raising their profile among the immigrant population.
Acknowledgements We want to thank all providers who voluntarily participated in this study and gave their time to be interviewed and shared with us their professional experiences. Without them, this study would have not been possible.
Sources of funding This study was financed by the National Health Institute Carlos III (Ministry of Health, Spain).
Conflict of interest All the authors declare that they have no financial and personal relationships with other
people or organizations which could inappropriately influence (bias) our work.
References 1 United Nations. Declaration on the Elimination of Violence Against Women. UN, 1993. Available at: http://www.un.org/documents/ga/res/48/a48r104. htm, accessed August 31 2014. 2 World Health Organization. Global and Regional Estimates of Violence Against Women: Prevalence and Health Effects of Intimate Partner Violence and non-Partner Sexual Violence. Geneva: World Health Organization, 2013. Available at: http://apps.who. int/iris/bitstream/10665/85239/1/9789241564625_eng. pdf?ua=1, accessed 14 July 2014. 3 Garcia-Moreno C, Jansen HA, Ellsberg M, Heise L, Watts CH. Prevalence of intimate partner violence: findings from the WHO multi-country study on women’s health and domestic violence. The Lancet, 2006; 368: 1260–1269. 4 Vives-Cases C, Gil-Gonzalez D, Plazaola-Castano J et al. Gender-based violence against immigrant and Spanish women: scale of the problem, responses and current policies. Gaceta Sanitaria, 2009; 23: 100–106. 5 Burman E, Chantler K. Domestic violence and minoritisation: legal and policy barriers facing minoritized women leaving violent relationships. International Journal of law and Psychiatry, 2005; 28: 59–74. 6 Ingram EM. A comparison of help seeking between Latino and non-Latino victims of intimate partner violence. Violence Against Women, 2007; 13: 159–171. 7 Kaukinen C. Status compatibility, physical violence, and emotional abuse in intimate relationships. Journal of Marriage and Family, 2004; 66: 452–471. 8 Lawson SL, Laughon K, Gonzalez-Guarda RM. Predictors of health care use among a predominantly Hispanic, urban sample of individuals seeking IPV services. Hispanic Health Care International: The Official Journal of the National Association of Hispanic Nurses, 2012; 10: 28. 9 Larchanche S. Intangible obstacles: health implications of stigmatization, structural violence, and fear among undocumented immigrants in France. Social Science & Medicine, 2012; 74: 858–863. 10 Bhuyan R. Negotiating citizenship on the frontlines: how the devolution of canadian immigration policy shapes service delivery to women fleeing abuse. Law & Policy, 2012; 34: 211–236. 11 Amanor-Boadu Y, Messing J, Stith S, Anderson J, O’Sullivan C, Campbell J. Immigrant and nonimmigrant women: factors that predict leaving
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and abusive relationship. Violence Against Women, 2012; 18: 611–633. Abu-Ras W. Cultural beliefs and service utilization by battered Arab immigrant women. Violence Against Women, 2007; 13: 1002–1028. Conyers J. The 2005 reauthorization of the violence against women act why congress acted to expand protections to immigrant victims. Violence Against Women, 2007; 13: 457–468. Official State Gazette. 18th Amendment to Organic Law 4/2000 on the Rights and Freedoms of Foreigners in Spain and Their Social Integration [Organic Law 2/2009 and the Corresponding Regulation for Implementation]. RD 557/2001, of April 2000. Spain, 2001. Available at: http://www. boe.es/boe/dias/2000/01/12/pdfs/A01139-01150.pdf, accessed 14 July 2014. Official State Gazette. Organic Law 1/2004, of 28th December, on Comprehensive Protection Measures Against Gender-Based Violence. Spain, 2004. Available at: http://www.boe.es/boe/dias/2004/12/29/ pdfs/A42166-42197.pdf, accessed 14 July 2014. Ministry of Labour and Social Affairs. Strategic Plan for Citizenship and Integration 2007–2010. Spain, 2007. Available at: http://extranjeros.empleo. gob.es/es/IntegracionRetorno/Plan_estrategico/pdf/ PECIingles.pdf, accessed 14 July 2014. Observatory against domestic and gender violence. Report on Victims of Gender Violence and Domestic Violence by Partner or Former Partner. Spain, 2011. Available at: http://www.poderjudicial.es/cgpj/es/ Temas/Violencia_domestica_y_de_genero/Actividad_ del_Observatorio/Informes_de_violencia_domestica/ Informe_sobre_victimas_mortales_de_la_violencia_ de_genero_y_de_la_violencia_domestica_en_el_ambi to_de_la_pareja_o_ex_pareja_en_2011, accessed 14 July 2014. Vives-Cases C, La Parra Casado D. Spanish politicians discourse about the responses to violence against women. Gaceta Sanitaria, 2008; 22: 451–456. Tanahashi T. Health service coverage and its evaluation. Bulletin of the World Health Organization, 1978; 56: 295–303. Hirmas Adauy M, Poffald Angulo L, Sep ulveda A, Aguilera Sanhueza X, Delgado Becerra I, Vega Morales J. Health care access barriers and facilitators: a qualitative systematic review. Revista Panamericana de Salud P ublica, 2013; 33: 223–229. Rodrıguez M, Valentine JM, Son JB, Muhammad M. Intimate partner violence and barriers to mental health care for ethnically diverse populations of women. Trauma, Violence, & Abuse, 2009; 10: 358–374. Frenz PVJ. Universal health coverage with equity: what we know, don’t know, and need to know. In: First Global Symposium on Health Systems
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Research. Montreux (Switzerland), 2010. Available at: http://healthsystemsresearch.org/hsr2010/images/ stories/9coverage_with_equity.pdf, accessed 31 August 2014. World Health Organization. Regional Net- Work for Equity in Health in East and Southern Africa. A Toolkit for Monitoring and Evaluating Equity in Access and Health Systems Strengthening in AIDS Treatment pro- Grammes: Concepts, Models, Methods and Indicators. Geneva: WHO, 2010. Available at: http://www.who.int/sdhconference/ resources/who_monitoring_equity_aids.pdf, accessed 31 August 2014. National Institute of Statistics. Population, 2013. Available at: http://www.ine.es/en/prensa/np788_en. pdf, accessed 31 August 2014. National Institute of Statistics. Statistic exploitation of the populational register 2013. Available at: http:// www.ine.es/jaxi/tabla.do, accessed 31 August 2014. Glaser BG, Strauss AL. Theoretical sampling. In: Denzin NK (ed.) Sociological Methods. A Sourcebook. Piscataway, NJ: Aldine Transaction, 1970:105–114. Patton MQ. Qualitative Evaluation Methods. Beverly Hills, CA: Sage, 1980. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology, 2006; 3: 77–101. Ortiz-Barreda G, Vives-Cases C, Gil-Gonz alez D. Worldwide violence against women legislation: an equity approach. Health Policy, 2011; 100: 125–133. Salazar-Torres C. La situaci on de las mujeres latinoamericanas vıctimas de la violencia de genero en Espa~ na en funci on de su situaci on administrativa [The situation of Latin American women victims of gender violence in Spain in terms of their administrative status]. Revista Estudios Jurıdicos Segunda Epoca, 2009; 9. Available at: http:// revistaselectronicas.ujaen.es/index.php/rej/article/ view/127/114, accessed 14 July 2014. Anitha S. Legislating gender inequalities the nature and patterns of domestic violence experienced by south Asian women with insecure immigration status in the United Kingdom. Violence Against Women, 2011; 17: 1260–1285. Erez E. Domestic violence and the criminal justice system: an overview. Online Journal of Issues in Nursing, 2002; 7: 4–4. Erez E, Hartly CC. Battered immigrant women and the legal system: a therapeutic jurisprudence perspective. Western Criminology Review, 2002; 4: 155. Aretio Romero A. [Ethical considerations involving reports by health professionals of violence against women]. Gaceta Sanitaria, 2007; 21: 273–277.
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47 Vidales GT. Arrested justice: the multifaceted plight of immigrant Latinas who faced domestic violence. Journal of Family Violence, 2010; 25: 533–544.
Appendix 1: Outline of questions to ask during the interviews* Opening Questions • Professional experience with immigrant women • Areas of experience Section I. Access to resources Women in general • Experience of assisting in cases of IPV • Women’s disclosure of IPV • Support received by women experiencing IPV • Intervention in cases where IPV is suspected Immigrant Women • Nationality • Differences in their help-seeking paths Section II. Case Follow-Up The critical path of immigrant women • Steps taken prior to accessing resources • Women’s evaluation of resources Returning to the aggressor • Explanation of cases • Reasons for return • Intervention taken to prevent return Filing a complaint • Experiences • Time of filing a complaint • Difficulties • Withdrawal of complaints Section III. Perceptions of Women Immigrants • Women’s interpretation of their experience • Difficulties encountered • Responses obtained to help-seeking • Evaluation of resources • Influence of administrative situation • Aspects influencing IPV Section IV. Suggestions for Improvement • Professionals’ needs • Success stories • Professional difficulties Closing Question Possibility of adding aspects not mentioned in the interview. *These questions were not always asked literally or in the same order, but provided an indication of issues to address, and were adapted to each individual case.
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Barriers and facilitators to effective coverage of Intimate Partner Violence services for immigrant women in Spain Erica Briones-Vozmediano PhD,* Daniel La Parra PhD†‡ and Carmen Vives-Cases PhD MPh‡§ *Research Assistant, §Senior Lecturer, Public Health Research Group, University of Alicante (Alicante), Spain, †Senior Lecturer, Department of Sociology II, University of Alicante (Alicante), Spain, ‡Senior Lecturer, Interuniversity Institute for Social Development and Peace, WHO Collaborating Centre for Health and Social Inclusion (Alicante), Spain and §Senior Lecturer, Epidemiology and Public Health CIBER (CIBERESP), Barcelona, Spain
Abstract Correspondence Erica Briones Vozmediano Research Assistant Department of Community Nursing Preventive Medicine & Public Health and History of Science University of Alicante San Vicente del Raspeig P O Box 99 E-03080 Alicante Spain E-mail: [email protected] Accepted for publication 16 September 2014 Keywords: access and evaluation, battered women, emigrants and immigrants, health-care disparities, Spain, women’s health service
Objective To explore service providers’ perceptions in order to identify barriers and facilitators to effective coverage of Intimate Partner Violence (IPV) services for immigrant women in Spain, according to the different categories proposed in Tanahashi’s model of effective coverage. Methods A qualitative study based on 29 in-depth personal interviews and four group interviews with a total of 43 professionals working in public services (social and health-care services, women’s refuges, the police force, the judiciary) and NGOs in Barcelona, Madrid, Valencia and Alicante (Spain) in 2011. Findings Current IPV services in Spain partially fail in their coverage of abused immigrant women due to barriers of (i) availability, such as the inexistence of culturally appropriate services; (ii) accessibility, as having a residence permit is a prerequisite for women’s access to different services and rights; (iii) acceptability, such as women’s lack of confidence in the effectiveness of services; and (iv) effectiveness, for example, lack of specific training among professionals on the issues of IPV and immigration. However, interviewees also identified facilitators, such as the enabling environment promoted by the Spanish Law on Gender-Based Violence (1/2004), and the impetus it has provided for the development of other specific legislative tools to address IPV in immigrant populations in Spain (availability, accessibility and effectiveness). Conclusion Whilst not dismissing cultural barriers, aspects related to service structure are identified by providers as the main barriers and facilitators to immigrant women use of IPV services. Despite noteworthy achievements, improvements are still required in terms of mainstreaming assistance tailored to immigrant women’s needs in IPV policies and services.
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Introduction Violence against women (VAW) is an extreme manifestation of gender inequality in society and a serious violation of fundamental human rights. The United Nations declaration on the Elimination of VAW defined it 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 acts such as coercion or arbitrary deprivation of liberty, whether occurring in public or private life.1 Intimate Partner Violence (IPV) against women is the most common type of male VAW. According to a recent WHO report on worldwide lifetime IPV prevalence rates, at least 30% of ever-partnered women have been abused by their male partner.2 Although IPV against women occurs without exception in all countries, all cultures and at every level of society, it may vary dramatically both between and within countries.3 There are cases such as Ethiopia, with a lifetime IPV prevalence of 70% and others such as Japan, with a prevalence rate of 15%.3 Within countries, some populations of women may be at greater risk. In Spain, a cross-sectional study of 10 202 women attending primary health-care centres reported an IPV prevalence rate of 27.9% in immigrants compared to 14.3% in Spanish women.4 Research has shown that immigrant women in abusive relationships have unequal access to the services provided by the host countries, due to the presence of barriers such as lack of fluency in the host country’s language, limited knowledge of available IPV-related resources and previous experiences of discrimination in their dealings with institutions and professionals.5–7 Furthermore, it has been demonstrated that this unequal access to IPV services observed between immigrants and natives interacts with other barriers, such as restricted opportunities to find decent employment or an income which would provide women with financial independence from their partners, length of residence in the host country and legal (or illegal) status.8–12
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Some governments are aware of these difficulties and have legislated to provide special protection measures for immigrant women and their children in abusive relationships, such as facilitating the process of achieving legal status in the host country.13 Spain is a noteworthy example of this, with policies aimed at facilitating access to social, health and legal services for abused immigrant women and providing the possibility of obtaining temporary residence and work permits.14–16 Despite these supportive policies, of the 62 deaths from IPV recorded in 2011, 35% were immigrant women; in the same year, 36% of the women who filed complaints against their aggressors in the courts or at the police station were immigrants, of whom 41% subsequently withdrew their complaint.17 In Spain, officially reporting a case of IPV is the only mean to access to public supporting resources for battered women.18 In his study entitled ‘Health Service Coverage and its evaluation’,19 Tanahashi proposed a model in which ‘health service coverage is considered as a concept expressing the extent of interaction between the service and the people for whom it is intended, this interaction not being limited to a particular aspect of service provision but ranging over the whole process from resource allocation to achievement of the desired objective’. This process involves a variety of factors related to availability of material and human resources, accessibility, acceptability, contact and effectiveness. Studies on abused immigrant women’s access to health services have predominantly focused on characteristics related to cultural factors (acceptability) or on legal aspects (accessibility), but have minimized the role of the health services (availability, effectiveness) or the key role of the interaction between the health services and the population.20,21 In spite of the fact that it was proposed in the year 1978, its current application has advantages for explaining elements facilitating or hindering the access or give up of services, according to the different stages of the model, where specific social groups – vulnerable populations – face different barriers and they do not have contact with services.22,23
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In this study, we explored IPV service providers’ perceptions of the barriers and facilitators to effective IPV service coverage of immigrant women, according to four of the analytical categories proposed by Tanahashi: availability, accessibility, acceptability and effectiveness.
Methods Setting and approach Twenty-nine in-depth personal interviews and four group interviews (with two or five participants each, n = 14 participants) were conducted with a total of 43 professionals involved in providing support to abused immigrant women. Forty of the participants were women and three were men, and they were employed in non-governmental organizations (NGOs) and public institutions related to VAW or immigrant populations with specific VAW programmes (Table 1). These professionals came from four different cities in Spain (Barcelona, Madrid, Valencia and Alicante); those cities concentrate 46% of the migrant women population of Spain, as there are more employment opportunities.24 Barcelona and Madrid are the two biggest cities of Spain, where migrant women represent the 9.6 and 8.5, respectively, of their general population; in Alicante, they are the 8.2% and in Valencia, the 5.4%.25 Sampling and data collection Theoretical sampling was used26 according to the different professional profiles of the public institutions and NGOs capable of contributing to our research question. The first participant recruitment strategy employed was to contact a women’s refuge in Alicante. Next, we recruited professionals via a social worker, who enabled us to contact professionals working with NGOs. Recruitment of the latter informants was achieved using snowballing. The interview guide was produced after reviewing the literature and considering the experience and knowledge of the research team. There was no predetermined sequential order,
and questions were open-ended. The interview was divided into four sections, concerning their experience with abused immigrant women and the problems encountered, the interventions carried out, their perceptions regarding immigrant women’s satisfaction with these interventions and resources, and their general evaluation and the possibility of improving support to abused immigrant women (see Appendix 1). The interviews were carried out at the professionals’ places of work between September 2010 and December 2011 by members of the research team and lasted for approximately 1 h. All the interviews were conducted in Spanish, which was the mother tongue for both interviewers and participants, and continued until data saturation was achieved, that is when no new information related to the research question was being obtained.27 In keeping with the principles of the Declaration of Helsinki and the Belmont Report, written informed consent was obtained from each participant prior to data collection. Data analysis The interviews were recorded digitally and then transcribed verbatim. All data were imported into qualitative analysis software Atlas.ti-5 (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany) and then examined using thematic analysis to identify pre-defined themes across the data set.28 Specifically, we classified barriers and facilitators into four areas (availability, accessibility, acceptability and effectiveness), according to Tanahashi’s model20 (Fig. 1). Although the remaining dimension of ‘Contact’ is useful for measuring ‘contact coverage’, or proportion of people in the target population who use the service, we decided to exclude it from this study because it does not indicate specific barriers or facilitators. In addition, this dimension is defined in quantitative terms, something which cannot be quantified from interviews with professionals. Through repeated readings of the texts, the authors discussed, negotiated and redefined these pre-defined themes related to Tanahashi’s
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Services coverage for abused immigrant women, E Briones-Vozmediano et al. Table 1 Professionals interviewed (n = 43)
Place of work Social Services
Associations/ NGOs
Law/Police
Interview code
Sex
Background
Professional profile
Area of work
City
1 2 3 4 5 6 11 12
Female Female Female Female Female Male Female Female
Social educator Psychologist Psychologist Social educator Social worker Social educator Lawyer Social worker
Employment educator Psychologist Educator Child educator Social worker Health educator Director Social worker
Shelter Shelter Shelter Shelter Shelter Shelter
Alicante Alicante Alicante Alicante Alicante Alicante Alicante Alicante
24
Females
25
Female
Psychologist Director IPV specialist
28 29 30 32 7
Female Female Female Female Females
8 9 10 13 14 15 16 17 18 19 20 21 22 23 26 27 31
Female Female Female Female Female Female Female Female Female Female Female Female Male Male Female Female Females
33
Female
Psychologist Social worker Social worker and anthropologist Social worker Social worker Psychologist Psychologist Social worker Sociologist Social worker Lawyer Mediator Former IPV victims Lawyer Mediator Health worker Psychologist Lawyer Social worker Lawyer Police officer Police officer Lawyer Police officer Lawyer 2 Psychologists 3 Social workers Judge
Social worker Social worker Psychologist Coordinator Workforce entry coordinators Social worker Lawyer Lecturer Former IPV victims Lawyer Mediator Health worker Psychologist Lawyer Social worker Magistrate Police officer Police officer Lawyer Police officer Lawyer Psychologists Social worker Judge
Council equal opportunities section Community centre
Barcelona
Specialist IPV service
Barcelona
Specialist IPV service Specialist IPV service Specialist IPV service Specialist IPV service Women’s association
Madrid Madrid Madrid Barcelona Alicante
Women’s association Immigrants’ association University Women’s association Immigrants’ association Immigrants’ association Immigrants’ association Immigrants’ association Immigrants’ association Immigrants’ association Specialist IPV court Specialist IPV police unit Specialist IPV police unit Specialist IPV court Specialist IPV police unit Specialist IPV court Specialist IPV court Specialist IPV court Specialist IPV court
Alicante Alicante Alicante Alicante Alicante Valencia Valencia Alicante Alicante Alicante Alicante Alicante Alicante Alicante Alicante Alicante Madrid Madrid Barcelona
IPV, Intimate Partner Violence.
definitions, dividing each theme into barriers and facilitators. To identify these themes across the data set and make sense of the pattern of responses, we generated codes from the data which identified meaningful sentences or paragraphs, reflecting a higher level of abstraction. These codes were sorted and grouped together according to pre-defined themes. The resulting description of the themes reflects the manifest content of the text, what the providers explicitly
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expressed about the process. In order to stay closer to the text, the original Spanish version was used for coding, and translation into English only took place once themes were identified.
Results Thematic analyses of the data identified barriers and facilitators of availability, accessibility, acceptability and effectiveness (Table 2).
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Target population: abused immigrant women
Figure 1 Tanahashi’s effective coverage stages, applied to an analysis of Intimate Partner Violence (IPV) services and resources. Adapted from Tanahashi.19
Availability Barriers The majority of the barriers that service providers mentioned affect both immigrant and native abused women, such as the lack of services (i.e. women’s refuges, job placement services, lack of access to housing or services for children such as nursery school) or the lack of human and/or material resources in existing services (i.e. financial assistance for integration or number of places in women’s refuges). With particular reference to immigrant women, service providers referred to the lack of services specifically for immigrant women. Far more resources are required. You need something specific for [immigrant] women. Not just in this service, but in all basic services specified by law and so on, and maybe much more protection is needed. . . Because they are much more unprotected (Interview 12: Social Worker, Woman).
Facilitators Professionals mentioned advances resulting from the Law on Gender-Based Violence (Organic Law 1/2004), which led to other
legislative changes on IPV, such as including specific measures for immigrant women. Progress is being made, we’re moving forwards all the time, that much is clear because the law is from 2004 and before that there was nothing /. . ./. Yes, but I still think it isn’t enough. (Interview 26: Police Officer, Woman)
Other improvements cited included the existence of information services, refuges, access to housing, financial assistance (welfare benefit), help in finding employment, psychological treatment, free legal assistance, advice and support, translation services and intercultural mediation. we explain all the resources available to them, the help they can get so that they know they can escape from the situation, that they don’t need to stay there because there are a lot of resources that they can use and take advantage of. (Interview 2: Psychologist, Woman)
Accessibility Barriers The main barrier for some immigrant women described by professionals is the lack of a
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Services coverage for abused immigrant women, E Briones-Vozmediano et al. Table 2 Barriers and Facilitators identified by different professionals from Intimate Partner Violence (IPV) services and NonGovernmental Organisations in Spain, 2011 Theme
Types of barrier
N professionals
Types of facilitator
N professionals
Availability
Lack of specific services and service resources
19
10
Accessibility
Requirement for regularised status Requirement to file a complaint Other requirements: administrative procedures Fear and vulnerability Fear of losing papers Fear of the aggressor Fear of the consequences of filing a complaint Lack of confidence in services Perceived disadvantage Lack of awareness Lack of training Lack of specific protocol Problems after filing a complaint Lack of coordination
21
Laws Support resources to escape from situations of violence Free provision
Acceptability
Effectiveness
18
Universal coverage Filing a complaint Linguistic proximity 32
Professional work Group interventions Information
12
18
Legislative progress Personal involvement Specific Resources
18
residence permit, as access to resources such as financial assistance, training courses to improve employability or free legal aid and defence is limited to women with a residence permit.
bureaucracy and they don’t manage to. . . (Interview 33: Judge, Woman)
Under the present Immigration Law, abused immigrant women who are in an irregular situation are entitled to a residence permit if they file an official complaint; however, administrative procedures are lengthy and complicated.
Furthermore, women may have to travel or even pay for documents from the country of origin, because the system does not assume all the costs. Providers claimed that these administrative delays complicate their interventions with immigrant women, because access to many of the available resources is dependent on possession of a residence permit, for example, help with job-seeking. For some immigrant women, another accessibility barrier mentioned is the requirement to file a complaint to acquire a residence permit or to access IPV services (according to the law, women must be granted a protection order before they are entitled to access to a refuge).
The so-called financial assistance is very limited, it’s very difficult to obtain, it requires a lot of paperwork, and these women don’t usually have the ability to apply for all of that, to endure it all, it’s very complicated, there’s a lot of
It’s a crying shame that in order to obtain emergency help you have to file a complaint, or that to be entitled to a series of employment rights you have to have a judgment or a protection order; it’s a pity because not everything works or
For a lot of women, not having the necessary papers prevents them from being independent. They can’t take courses, they can’t look for work, and we’ve found that they’re not even eligible for social services here. If they haven’t got papers, there’s a huge rigmarole entailed in obtaining a health insurance card. . ., that’s a problem that for me represents a very important barrier. (Interview 6: Health Educator, Man)
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2999
3000
Services coverage for abused immigrant women, E Briones-Vozmediano et al. even ought to work like that. (Interview 30: Psychologist, Woman)
This is especially the case for those women with a family residence permit, because they do not want their husbands to lose their permits or to endanger the family finances. In addition, lodging a complaint involves several risks for immigrant women if their complaint cannot be proven due to lack of evidence, such as losing their temporary residence permit. How many are there, how many, how many don’t we know about because they’re frightened of filing a complaint, because if then it’s proven false, they deport you, eh? That’s one of the hardest decisions for women to make, especially because so many don’t have papers and they can’t, they don’t seek help, they stay, they stay chained to the abuser. (Interview 7: NGO Professionals, Women)
Facilitators The facilitators to access to services identified by professionals included their free provision, when the economic costs are borne by the system, When they file a complaint, they are informed of their right to assistance from a lawyer specialising in gender-based violence. The first consultation is free, and after that it will depend on their income as to whether it remains free or not. (Interview 21: Police Officer, Woman)
the possibility of obtaining residence and work permits on establishing their status as women victims of IPV (through filing a complaint) We help any woman at risk of social exclusion, irrespective of whether she has papers or not, whether she’s from Spain or elsewhere. /. . ./ We don’t even ask if she’s registered with her local council, or where she lives, none of that. Any woman who’s at risk, who’s in a situation that means she needs help, must be helped. (Interview 8: Social Worker, Woman) In the case of a victim of gender-based violence, if she files a complaint this serves to regularize her situation. (Interview 26: Police Officer, Woman)
and, in the case of Latin American immigrant women, their linguistic proximity, which favours communication with professionals and increases these women’s confidence in the services and in the professionals themselves. One of the elements which is a greater facilitator for Latin American than other immigrant women is the language (Interview 24- Psychologist and Social Worker, Woman)
Acceptability Barriers The main acceptability barrier was described by professionals as being the fear experienced by immigrant women. They not only fear the offender, but also the socio-economic, legal or administrative status consequences for themselves and/or their children after initiating a legal process by filing an IPV complaint. Not being near their family, fear of deportation, the fear is always there, then there’s the fear that the aggressor will threaten to take their children away and take them off to his country, /. . ./ Clearly, all this makes immigrant women much more vulnerable. Even if you tell an immigrant woman without papers that they give you a residence permit for gender-based violence, there’s always that fear. Then there’s the economic level, because they [the aggressors] use this to intimidate the women: Look at you, you haven’t got any money, they’ll take the children off you!. . . How can you have the children if you haven’t got any money? (Interview 12: Social Worker, Woman) Retaliation, fear of retaliation, fear of failure, fear of what people will say, fear, fear and more fear means that, well, most of them take a long time to file a complaint. (Interview 10: Mediator, Woman)
Providers claimed that due to negative experiences of IPV services in the past, some immigrant women now lacked confidence in their effectiveness. In this respect, for example, some professionals mentioned the difficulties involved in living in women’s refuges.
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Services coverage for abused immigrant women, E Briones-Vozmediano et al. And because they get sent to a women’s refuge, which is often another battle Refuges aren’t easy places to be /. . ./ Living in a house where you don’t know anyone and you’re not interested in living with these people, each with their own problems. (Interview 7: NGO Professionals, Women)
In addition, professionals noted that immigrant women subjectively feel that as foreigners, they do not have the same rights as native women (i.e. in the judicial system or as regards police protection and social services), and that this is linked to their feeling of being discriminated against, not only in terms of services, but by society as a whole (in the street, in employment, etc.). They don’t feel they belong, they feel like they are going to get less response because of not being from here, they feel inferior. /. . ./ Because they’re not from here, they don’t feel like they have the same rights, so they don’t take this step with the same confidence as a Spanish woman might have. . . (Interview 13: Victim Association Group, Women)
Facilitators The professionals emphasized that it was part of their job to reduce acceptability barriers when immigrant women used IPV services. This they did by fostering trust, giving information about the existence and characteristics of the different services and providing guidance. As far as possible, we try to tell them about all the measures, to encourage them in every way possible, to get them to talk honestly with us and to tell us what happened, to open up, in the sense of telling us everything, of not leaving anything out, that we are there to help them, that this is something that they don’t have to put up with, that it’s normal to report it, I mean we do absolutely everything possible to get them to tell us what happened. (Interview 22: Police Officer, Man)
They also organized information dissemination activities and group workshops, which helped raise awareness about violence and the services available to tackle it. This programme takes into account that when a woman comes from a situation of violence she
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hasn’t got any resources, she hasn’t got a social network, she doesn’t know where to go. So the programme gets to work on that part with them, to work on all these aspects to improve their possibilities. For example, the self-esteem workshop focuses on getting them to take an active role, to take personal decisions, to develop and to receive training. (Interview 7: NGO Professionals, Women)
Providers believed that acculturation processes (understood as assimilation of the target culture) can lead to a break with immigrant women’s own cultural patterns, which may have served to legitimize violence (especially with reference to patriarchy). It is considered an offence here, whereas it may not be in their country of origin. Over there, they wouldn’t have dreamt of reporting it, but when they file a complaint here they admit that they received far more abuse in their own country than they do here, but that it was seen as normal over there, and it’s only once they’re here that they begin to think about, and not only think about, but also go about seeking help, or getting out of the situation, something which was unthinkable there (Interview 31: Social workers and psychologists, Women).
Effectiveness Barriers In general, professionals complained of a lack of specific training in and awareness about IPV and immigration in their sectors. For psychologists, it is difficult to conduct therapy with women through an interpreter, who may not be sensitive about IPV, where this option is available. There’s still a lack of awareness in many courts /. . ./ I’m sick of seeing lawyers who are on immigration duty and haven’t got a clue, and I’m sick of seeing lawyers who are involved in the issue of violence and don’t understand gender-based violence, don’t understand the first thing about it. (Interview 28: Lawyer, Woman) Often, professionals haven’t received sufficient training /. . ./. Nobody’s been trained, not in the courts, not. . . I think the first thing they should do is to teach professionals how to deal with this
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we do not adopt a series of economic measures for her: we leave her totally defenseless. . . (Interview 27: Lawyer, Woman)
A barrier to the effectiveness of resources identified by providers consisted of a lack of specific measures which meet the needs of immigrant women, such as rapid processing of work and residence permits. The additional difficulties faced by some immigrant women, such as lack of social support or economic resources, imply greater obstacles to their empowerment through access to employment and housing.
Facilitators The professionals highlighted the change brought about by the Law on Gender-Based Violence (Organic Law 1/2004), which compensates irregular status, or the development of specific services to meet the needs of immigrant women (i.e. intercultural mediation, immigrant or pro-immigrant associations, or specific training for professionals).
Within what is the present protocol, there should be something for women who require more specific, personalised treatment. (Interview 6: Health Educator, Man)
The law reform already specifically provides women with the opportunity to obtain residence and work permits. It’s moved forwards. (Interview 14: Lawyer, Woman)
Lastly, they highlighted the fact that the need to file a complaint before access can be obtained to some services and benefits determines the ineffectiveness of other resources. Firstly, because many immigrant women fail to take this step; in fact, some professionals considered that this decision needed to be thoroughly prepared, which would imply working with them directly for some time. Right, because they tell you to file a complaint, that they’ll support you, they’ll offer you the opportunity to move on and start a new life, but then you get here and that possibility doesn’t exist. (Interview 4: Social Educator, Woman)
Secondly, the IPV resources available to women once a complaint has been filed may be somewhat limited (i.e. insufficient level of police protection, limited financial assistance and lack of help in job-seeking) or slow (such as processing of residence and work permit applications). These situations affect the effectiveness of the services and in some cases explain why a woman who has filed a complaint subsequently returns to her abusive partner. When the woman files a complaint, on the one hand we do protect her and we tell her that the aggressor must keep his distance, but then we leave her without an income, without the least provision for use and enjoyment of housing and
A woman has the right to be helped in her own language, a woman expresses herself in the language she knows, we have interpretation services. (Interview 32: Psychologist, Woman)
Providers also highlighted their work as a means to increase the effectiveness of resources. They emphasized the need for personal involvement to alleviate some of the weaknesses of the system mentioned above, for example by studying the languages of the women they serve, helping them to get job interviews or simply investing more time to ensure empathic communication with these women. Luckily, most of the people who work here put a lot into it, a lot of their inner self, I mean, this isn’t an NGO but it forces you, you can’t just leave a woman like that and sometimes you do what you have to and more. (Interview 27: Lawyer, Woman)
Discussion The results of this study indicate that there are considerable barriers in Spanish IPV services to the provision of assistance for immigrant women. These are related to (i) availability, such as insufficient human and economic resources in some services and benefits, and the
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lack of culturally appropriate services; (ii) accessibility, particularly in the case of immigrant women without a residence permit, which is required to access some services and benefits, but also due to aspects such as economic barriers to some procedures and services, and geographical distance; (iii) acceptability of the services, as a result of aspects such as cultural distance or lack of confidence in IPV services; and (iv) effectiveness, given the problems that have been detected as regards coordination between services or in relation to a lack of training among professionals in how to provide effective assistance to immigrant women. Facilitating factors included the major impetus provided by the Law on GenderBased Violence (Organic Law 1/2004), which increased the provision of IPV services not only for immigrants but also for the entire population. Specifically, with regard to the immigrant population, the 2009 reform of the immigration act has also been important, because it entitles immigrant women who file a complaint about a situation of violence to access a series of services and to regularize their legal status. Indeed, filing a complaint is the principle means in Spain for women victims of IPV to obtain assistance and protection measures, whether they are immigrant or not.18,29,30 For this reason, the main barriers mentioned by professionals to access to IPV services are related to the prior step required to access these services, that is barriers to filing a complaint.12,30–34 Despite there are some crosscutting issues (such as complaints and immigrant status), each specific barrier and facilitator fit into Tanahashi’s framework in one dimension exclusively. On the one hand, each step to fill a complaint constructs a different barrier: for example, the doubts before taking the decision, the fear of the consequences (for the aggressor and for themselves) of filling the complaint or following the process activated by the official complaint. On the other hand, economic resources could be a barrier to: travel to the required places to inform themselves, to fill a complaint and to follow the process; and for taking the decision
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of leaving the aggressor (if women are not economically independent). The main limitation of this study has been the decision to use an indirect strategy to study barriers to immigrant women’s access to IPV services, consulting professional service providers rather than talking directly to immigrant women who are victims of violence. In part, the barriers identified in this study correspond to those reported by the immigrant population in other studies.30,35–39 However, there is a tendency to focus on what could be called a cultural or socioeconomic ‘deficit’, locating the main barriers in areas such as language or communication, the cultural distance with IPV services, psychosocial determinants or problems related to immigration status (lack of documentation, poverty, lack of social support, etc.).12,40–44 Focusing on the perspective of professionals has yielded information with which to address questions related to aspects such as service organization or resources, or the training received by professional teams.5,8–12,44,45 As an important next step, further research should include interviews with immigrant women to test whether these are consistent with the service providers’ views. On the other hand, the majority of interviewees were women because most of the people working in IPV services are women, a circumstance which can be considered a facilitator in terms of acceptability as it inspires trust among some groups of immigrant women such as Muslim women.12 Numerous implications for practice can be derived from the analysis presented here, such as the importance of institutional strategies to remove barriers to access for the immigrant population.46 To achieve this, IPV services must be culturally appropriate, and it is also necessary to improve their coordination, invest in the training of their professionals and provide them with material and human resources, among other aspects.5,29,47 An exhaustive study is required on the specific assistance needs of the immigrant population. In the case of immigrant women, in addition to improving specific services, it is also important to consider the reform of general aspects
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such as facilitating residence permit procedures, through increasing the provision of information for women and establishing links with the diplomatic services of the countries of origin (for example, to efficiently process documentation or provide transnational protection), to rethink the stance of the Law on Gender-Based Violence (e.g. designing intervention strategies which are not limited to cases where a complaint has been filed and/or to improve employment opportunities, housing or services for children).
Conclusion Whilst not dismissing cultural barriers, by focusing in this study on the views of service providers and conducting an analysis in order to identify barriers and facilitators to effective coverage according to Tanahashi’s model, we have also identified aspects related to service structure, such as organization, provision of human and material resources, level of expertise in attention to diversity, professional training, coordination between services, economic and time costs for victims, the inadequacy of some services as regards addressing the specific needs of users, administrative difficulties and problems encountered by institutions in raising their profile among the immigrant population.
Acknowledgements We want to thank all providers who voluntarily participated in this study and gave their time to be interviewed and shared with us their professional experiences. Without them, this study would have not been possible.
Sources of funding This study was financed by the National Health Institute Carlos III (Ministry of Health, Spain).
Conflict of interest All the authors declare that they have no financial and personal relationships with other
people or organizations which could inappropriately influence (bias) our work.
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Appendix 1: Outline of questions to ask during the interviews* Opening Questions • Professional experience with immigrant women • Areas of experience Section I. Access to resources Women in general • Experience of assisting in cases of IPV • Women’s disclosure of IPV • Support received by women experiencing IPV • Intervention in cases where IPV is suspected Immigrant Women • Nationality • Differences in their help-seeking paths Section II. Case Follow-Up The critical path of immigrant women • Steps taken prior to accessing resources • Women’s evaluation of resources Returning to the aggressor • Explanation of cases • Reasons for return • Intervention taken to prevent return Filing a complaint • Experiences • Time of filing a complaint • Difficulties • Withdrawal of complaints Section III. Perceptions of Women Immigrants • Women’s interpretation of their experience • Difficulties encountered • Responses obtained to help-seeking • Evaluation of resources • Influence of administrative situation • Aspects influencing IPV Section IV. Suggestions for Improvement • Professionals’ needs • Success stories • Professional difficulties Closing Question Possibility of adding aspects not mentioned in the interview. *These questions were not always asked literally or in the same order, but provided an indication of issues to address, and were adapted to each individual case.
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