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

Background Domestic violence (DV) 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 DV 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 DV. 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 condentiality, 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 DV. 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 DV is clearly limited. Our ndings can inform training of health professionals in Palestine to address these barriers, to increase awareness of the link between DV and many common presentations such as depression, to ask sensitively about DV in private, reassure women about condentiality, and increase awareness among women of the role that health services can play in DV.


Background
Domestic violence (DV) 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 in 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 DV such as depression, sleep problems, abortion, pain, and hypertension (4), (5), (6), (7), (8), (9). DV 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 DV by 2030 is the second item of the UN 5 th 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 DV (15)(16) (17). Similar barriers were identi ed among women from eastern Mediterranean countries (18).
Studies show that women who have experienced DV 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 DV, or how they feel about disclosing their experience of violence in health care settings. The study reported here aimed to articulate Palestinian survivors' of DV attitudes towards and experiences of disclosure in a health setting. It is the rst qualitative study to explore barriers to disclosure of DV 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 DV, we conducted 20 semi-structured interviews with Palestinian women survivors of violence. This article presents results from the qualitative interviews.

Recruitment and sample
The Women's Centre for Legal Aid and Counselling (WCLAC) in the Occupied Territories of the West Bank of Palestine was contacted to help with recruitment of women survivors of DV. WCLAC provides legal and social support services, free of charge, to survivors of DV. Purposive sampling was used in order to recruit as wide a range of women as possible. Eligible women were aged 18 and over, and were receiving support from WCLAC following exposure to DV. To maximise geographical and social diversity, two centres were used for recruitment, one located in Ramallah and the other in Hebron. Two social workers in each location, aiming at a range of age and marital status, approached survivors and asked for their consent to be interviewed. Women who agreed to participate were interviewed by AS or Rania Abu-Aaita, a member of the research team who received training in qualitative interviewing

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 DV, 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. This enabled members of the international multi-lingual research team to advise, quality check and provide mentoring in the skills needed for qualitative analysis. 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)nductive approach was taken to the analysis, using the constant comparison technique (21). Transcripts were read and re-read by three members of the team, ME, SA and AS, who noted emergent topics and themes. These were discussed and a coding frame was developed as a group process. The coding frame was amended as new transcripts were analysed, until saturation of concepts was achieved. A sample of transcripts were double coded for veri cation. NVIVO 11 was used to facilitate the coding and analyses.
Trustworthiness and rigour of the study were maintained by ensuring credibility, dependability and transferability (22). The credibility of this study was accomplished via peer checking and a prolonged engagement in the data over six months. Dependability was achieved by an audit trail. Transferability was accomplished by selecting participants who had direct experience of the phenomena under investigation (23).

Characteristics of participants
All the contacted women agreed to participate. Most of the women were in marriages arranged by their families and the majority were separated or divorced. Although three women self-de ned as 'Married' (ie: Still in the relationship) rather than 'Separated' or 'Divorced', none of them were living with their husband at the time of interview. Thirteen women had children living at home with them (between one and seven children per household), one was pregnant at the time of interview, and four women had children who were no longer at home. 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 DV (DV) to health care providers Eleven out of the twenty interviewed survivors said that they had disclosed DV 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 DV 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 Women described their dependence on their husbands, both nancially and in terms of cultural expectations about how a married woman should behave. They were reluctant to talk about relationship di culties, matters considered 'too personal', and likely to result in them being blamed, shamed or embarrassed. None of the women were living with their husbands at the time of interview. Although some were already divorced, others were contemplating whether or not to take this step.
"I felt like I would be blamed for it [relationship di culty with her husband] and people might say; look, she let out secrets between her and husband. Why would she say that? So that would make me shy, embarrassed to talk about it" [39 year old woman, Hebron]. Feeling 'protected' by marriage was also nancial. Exposing violence in the home might lead to separation and divorce, with no guarantee of nancial support for the woman or her children. Fear of living apart from their children was a major barrier for women to disclosure. Women were also reluctant to seek help, especially for psychological distress, for fear of being labelled 'mentally ill'. Losing their credibility as a competent wife or mother might lead to them losing custody of their children. 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 DV. These women wished that, when they were in the hospital with signs of DV, the HCPs would ask them about how they were feeling and give them a chance to talk about DV.
"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 non-disclosure 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].
These women wished that, when they were in the hospital with signs of DV, the HCPs would ask them about how they were feeling and give them a chance to talk about DV.
One woman's obvious distress was ignored. Despite her tears, the HCPs carried on ' as normal'.
"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.
"no, she asked me. she asked me "what's going on? I feel like you're not all right?" I told her "I'm having some problems with my husband." [32 year old woman, Ramallah].
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 'DV' 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. Expectations of women's role Women described their society as 'repressive' and they were fearful of being judged if they talked about DV or left their husbands.
"Honestly no, because I never thought I'd ever le a complaint against him in my life. Firstly, for the sake of my kids and then because women are always violated. No matter what you say, your name and subject is going to be on the tip of everyone's tongues" [36 year old woman, Hebron].
One woman whose husband was in prison for DV 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 'home-wrecker' 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].
This woman felt wrongly blamed for speaking up about DV from her husband, who she addresses as 'you'.
"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.

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.

Discussion
Barriers to women survivors' help-seeking for DV in the Occupied Palestinian Territories involve a complex interplay of factors at several levels (individual, service and societal). Studies in other countries have led to the development of a multi-level conceptual framework for understanding help-seeking among survivors of DV (15,24). This framework suggested by Liang provided a model for guiding the data analysis in this study. A signi cant nding is that normative cultural values about women's role in Palestinian society exert a strong in uence, leading to barriers to disclosure of DV at all levels of women's experience, the individual, service and societal.
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 DV. However, women's agency to be proactive in helpseeking 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. Customs and behaviours ensure that men maintained their dominant social roles over women, a concept for which Connell coined the phrase 'hegemonic masculinity' (25). Men expect their wives and children to respect them, and to comply with their roles and demands. In this context there are many examples of the normalisation of DV, and few opportunities are available for women to talk about DV either in their informal networks or to professionals (26), (27). 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 DV is perceived as a private issue, and that sharing experiences with others would not be accepted (28)(29). 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 DV guidelines for HCPs, and protocols for how to respond to disclosure, which were recognized as challenges to the health service's response to DV (30). 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.
Women's experience of domestic violence in the Occupied Palestinian Territories and di culty in obtaining support, is exacerbated by the violence created by the existence of the occupying settler state (31). Women are particularly vulnerable to violence from male perpetrators who are themselves living in a situation of con ict and violence, leading to a sense of disempowerment (32). Women also suffer geographical suppression whereby access to health care facilities is di cult if they have been displaced from their usual territory or have to cross checkpoints (33).
In order to decrease DV, a focus group of young Palestinians from Gaza recommended raising awareness among Palestinian women toward their legal rights and the available services (34). 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 (26) and corroborates many of the ndings in the present study as regards health service barriers to disclosure (30).
The role of health care systems in responding to DV 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 DV and responding appropriately.

Strengths and Limitations
Strengths This is the rst study to investigate barriers to disclosure among Palestinian women in the Occupied Territories of the West Bank who are exposed to DV.
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.

Limitations
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 DV.
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 DV should be tailored to address the barriers to disclosure experienced by survivors, for example, how to ask sensitively about DV in private, the importance of reassuring women about con dentiality, and increasing awareness of the link between DV 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 DV is crucial.

Declarations
Availability of data and materials The data that support the ndings of this study are available from the corresponding author upon reasonable request.

Competing interests
The authors declare that they have no competing interests. Funding