'We don't see because we don't ask': Qualitative exploration of service users' and health professionals' views regarding a psychosocial intervention targeting pregnant women experiencing domestic and family violence.

INTRODUCTION: Given the relative recency of Domestic and Family Violence (DFV) management as a field of endeavour, it is not surprising that interventions for addressing DFV is still in its infancy in developing countries. In order to maximise the success of an intervention, it is important to know which aspects of the intervention are considered important and helpful by service providers and service users. This study, therefore, examined the acceptability of an antenatal-based psychosocial intervention targeting DFV in Nepal and explored suggestions for improving the program in future.
MATERIALS AND METHODS: Intervention participants and health care providers (HCPs) were interviewed using semi-structured interviews. Data were audio-recorded and thematic analysis was used to analyse the data. Final codes and themes were identified using an iterative review process among the research team.
RESULTS: Themes emerging from the data were grouped into domains including perceptions towards DFV, impact of the intervention on women's lives and recommendations for improving the program. DFV was recognised as a significant problem requiring urgent attention for its prevention and control. Intervention participants expressed that they felt safe to share their feelings during the counselling session and got opportunity to learn new skills to cope with DFV. The majority of the participants recommended multiple counselling sessions and a continued provision of the service ensuring the intervention's accessibility by a large number of women. DISCUSSION: This is the first study to document the perspectives of women and HCPs regarding an antenatal-based intervention targeting psychosocial consequences of DFV in Nepal. There was a clear consensus around the need to engage, support and empower victims of DFV and the intervention was well received by the participants. Ensuring good mental health and wellbeing among victims of DFV requires work across individual, organisational and community levels.

Introduction

Domestic and Family Violence (DFV) has been identified as the greatest social epidemic of this modern era, with the problem at a higher magnitude in developing countries [1]. It is an increasing physical, psychological and economic health burden, affecting nearly 35% of women globally and 26% in Nepal [1, 2]. Being pregnant is a key risk factor for the beginning and/or escalation of DFV [2]. DFV during and around the time of pregnancy is associated with a wide array of mental health problems [3] and significantly poorer quality of life [4].

Nepal is among those countries, which have criminalised DFV as well as having adopted several policy and programmatic steps to better respond and prevent DFV [5, 6]. As of September 2018, One Stop Crisis Management Centres (OCMCs) have been established in 45 districts, with the aim of providing integrated services such as appropriate referrals and empowerment to survivors of violence [7]. However, recent studies have shown that only the most severe victims of DFV tend to visit these centres suggesting that most of these incidents go underreported [8]. Several bottlenecks both on the demand as well as supply sides were noted [5, 9]. For example, in terms of demand, because of the social stigma and fear associated with DFV, and lack of awareness, women are reluctant to seek support services (only 34% of women seek formal support services) [10]. Similarly, some of the supply or service side challenges such as lack of coordination between national bodies and local organisations as well as lack of sufficient resources make the programmes insufficient in number, irregular and typically short-term [5, 7]. Nonetheless, these government and non-government initiatives are certainly steps in a right direction, however, currently they are insufficient in number and have not been implemented properly [6, 7]. This protracted change provides a rationale to seek out an intervention that can be implemented at a low-cost and can be made accessible to a larger population of Nepal.

With a growing recognition of need and urgency to address DFV, several intervention strategies have been designed and implemented, particularly in developed settings [11, 12]. However, sufficient evidence does not exist to guide health care providers (HCPs) and policy makers on the best way to address the needs of victims. A recent review about interventions targeting DFV among pregnant women in low-and middle-income countries (LMICs) identified some beneficial effects of screening and supportive counselling with a provision of referral to support services [13], in alignment with previous findings [14, 15]. In a resource limited setting such as Nepal, where services for DFV are insufficient in number or are just emerging [8], screening for DFV alone can be a good initiative to inform women about DFV and the appropriate referrals of victims could contribute to an improvement in their health and well-being [15, 16]. Antenatal care (ANC) has been the recommended setting for implementation of such a screening and referral intervention [13, 17].

Based on the available evidence and theories, a brief psychosocial intervention was designed to screen victims for DFV and address their immediate mental health needs. Furthermore, the intervention intended to support women in adopting safety behaviours and strengthening social support. The intervention was piloted in an ANC clinic within a tertiary hospital in Nepal. Pregnant women allocated to the intervention group were provided with a single session of counselling by a trained nurse, an information booklet and telephone support. The intervention nurse (DS), principal investigator of this study, is a trained counsellor and has past and present involvement in several research projects related to DFV. An intervention delivery guide was developed after several rigorous development and planning sessions within the research team and the intervention nurse adhered to this guide while delivering the intervention to the participants. The detailed description about the intervention and its delivery is published elsewhere [18]. Table 1 briefly illustrates the components of the intervention.

Table 1

Components of the piloted intervention and activities conducted.

Intervention component	Details of the activities conducted
DFV screening	Pregnant women (24–34 weeks of gestation) attending the ANC clinic were screened for presence of DFV including psychological, physical and sexual violence.
Supportive counselling	IG: Women were asked about their present concerns and were counselled accordingly. Brief information about DFV and its common mental health impacts were discussed. Women were provided with different problematic situations (based on the information booklet) and encouraged to express the way they would react in the given situation. Women’s responses were supplemented with additional information based on the information booklet. Women were asked about the safety behaviours they were currently practising to prevent them from revictimisation, and the counsellor informed them about other possible alternatives to adopt in future. A single session of counselling was conducted by a nurse (DS) which lasted for 35–45 minutes.
	CG: Women were asked about their general health and wellbeing and were provided with key information on pregnancy and post-partum care.
Information Booklet	IG: Women were provided with the information booklet which included key information about DFV, approaches to address common mental health consequences of DFV, and safety planning behaviours. They were provided with the contact details of local support services against DFV. The booklet also included general information on pregnancy and postpartum care.
	CG: The information booklet included contact details of local referral services and general information on pregnancy and postpartum care. (Both booklets had same front cover and were given a neutral title to ensure confidentiality and participants’ safety).
Telephone support	IG: Participants were provided with the contact details of the counsellor so that they could contact her at times of need at any time during the study period.
	CG: No contact information was provided.

IG: Intervention group; CG: Control group

Employing both qualitative and quantitative research methods in trials has been greatly acknowledged in modern social research [19], particularly if the trial is related to complex health-related issues, such as DFV [20]. Besides developing a clinically effective intervention, it is also essential for interventions to be person-centred to maximise its effectiveness and engagement. Qualitative studies are a useful way of exploring participants’ experiences of interventions and have often been used to understand the acceptability and engagement with those interventions [21]. Insights from qualitative research can inform if the implementation of an intervention is successful and can also identify any modifications desired by the participants to ensure its applicability and accessibility in the future [22]. Hence, a nested qualitative study was conducted with the following specific objectives:

To explore the perceived strengths and limitations of the counselling and psychoeducation intervention as experienced by intervention participants and HCPs.

To solicit feedback on what elements of the intervention and process could be improved and how.

Materials and methods

Design

This study was nested within a trial conducted in an ANC clinic of a tertiary hospital in Nepal [23]. BP Koirala Institute of Health Sciences (BPKIHS) was selected purposively as it has wider catchment areas and nearly 100–150 pregnant women visit this hospital every day [23]. This trial has been registered in the Australian New Zealand Clinical Trial Registry (ANZCTR) with the registration number 12618000307202. A descriptive qualitative approach was implemented for this study. During initial assessment and participant recruitment, all participants in the intervention arm were asked if they would be willing to participate in qualitative interviews after receiving the intervention. All participants agreed to be interviewed. The study conduct and reporting adheres to the Consolidated Criteria for Reporting Qualitative Research (COREQ) [24]; see Supporting information S1 COREQ checklist.

Data collection

Using an open-ended interview schedule, the research nurse (RP) asked women from the intervention group about the acceptability, strengths and weaknesses of the intervention during their follow-up visits, which occurred at: i) 4–6 weeks after the intervention; and ii) 6 weeks post-birth of a baby. DS (the intervention nurse) used a flexible interview topic guide for interviewing HCPs as it enabled a wider range of participants’ views and experiences to be captured. In addition to the feedback regarding the piloted intervention, HCPs were asked about their views regarding DFV and efforts to address it in their context (see Supporting information S1 Interview schedule). Both interviewers (RP and DS) are registered nurses and have experience in conducting qualitative interviews. Purposive sampling was used to select the HCPs who could provide the most pertinent information related to the research topic and objectives. Interviews with the women lasted for about 15–20 minutes and with HCPs the length of each interview was on an average 30–45 minutes. Face-to-face interviews were conducted at the hospital; for women who were unable to come to the hospital, interviews were conducted via telephone. Adhering to the World Health Organization (WHO) ethical guidelines [25], the interviewer ensured that if the call was answered by the participant and it was safe for her to talk. If not, the woman was asked to call back at any time feasible for her. All the interviews were digitally recorded, fully transcribed verbatim and given a unique identification number to ensure anonymity of the study participants. Responses from the participants were also noted down on paper. Those notes were read in conjunction with the transcripts to ensure complete and appropriate interpretation of the information. All data were organised and managed using Microsoft Word and Excel spreadsheet.

Data analysis

Data were analysed using inductive thematic analysis, consisting of six phases [26]. The phases were familiarisation with transcripts, forming initial codes, searching for themes, reviewing themes, defining and naming themes and developing report [26]. First, transcripts were read and reread to ensure familiarity. An initial coding frame was developed by two raters (DS and RP) for three transcripts with the HCPs and 10 with the intervention participants. A coding framework was iteratively discussed among the researchers and any disagreement on codes were resolved on consensus. DS then coded remaining transcripts using the initial coding framework and discussed new codes with the other authors (DA, KB, AS) as they emerged, ensuring that the codebook was regularly updated. Coded chunks of data were initially grouped into categories and relevant themes, and all transcripts were read several times to capture all emerging themes and to extract supporting excerpts. Inconsistencies were discussed during joint meetings with the research team and themes were further developed [26]. The final stages of the analysis involved all authors reviewing and confirming the themes and subthemes in relation to the coded extracts, and ensuring that the analysis was logical and valid. Initial examination was made to assess for differences in the themes for interviews undertaken at first and second follow-up visits. However, the examination found no major differences by time-point and after discussion with the study authors, it was decided to present the data together as a whole piece.

Trustworthiness/Rigour

The criteria described by Lincoln and Guba was applied to enhance trustworthiness in this study [27]. Credibility was enhanced by prolonged engagement, as the first author (DS) grew up, lived and worked in the research setting. By its very nature, qualitative research normally produces an enormous amount of data, requiring researcher interpretation, which was achieved by the researchers actively engaging with the text. A triangulation of researchers helped to provide diverse perspectives to the data. To strengthen trustworthiness and avoid missing any information during data analysis, hand notes were reviewed along with the transcripts. To stay closer to the text, the original Nepalese version was used in the coding process and translation into English took place once themes were established. The inclusion of the quotes in the findings allows readers to judge the interpretations made. All these attempts are believed to enhance the confirmability of the findings. A detailed description of the research processes used has ensured trustworthiness in the analysis and where appropriate, the findings can be transferred to other settings.

Ethics approval and informed consent

The study received ethical approval from the Griffith University Human Research Ethics Committee, Nepal Health Research Council (NHRC), and Institutional Review Committee of BPKIHS. Written informed consent was obtained from all the study participants and they were assured that all their data would be treated confidentially and would be made non-identifiable. All participants were assured that they could withdraw from the study at any time. The study was conducted in adherence to the WHO’s ethical and safety recommendations for research on violence [25].

Results

Characteristics of the sample

A total of 63 women at the first follow-up and 51 women at the second follow-up, belonging to the intervention group, were asked about their views and opinions regarding the intervention. Pregnant women (24–34 weeks of gestation) having a history of DFV were recruited in the study. A total of seven HCPs (3 nurses, 2 obstetricians/gynaecologist, 1 health manager, and 1 Midwifery Professor) were interviewed. Among the three nurses, one was a Prevention of Mother to Child Transmission (PMTCT) counsellor, one was a nurse in-charge of the obstetrics and gynaecology outpatients department (OPD) and one was a nurse in-charge of the antenatal ward. A number of themes and subthemes were identified and they were grouped under several domains reflecting the research questions (Fig 1).

Fig 1

Overview of domains, themes and subthemes.

This figure shows the three overarching domains and the related themes and subthemes that emerged from the analysis.

Domain 1: Snapshot of Domestic and Family Violence (DFV)

HCPs were asked to comment on the burden and existing response mechanisms of DFV. This domain is divided into the following three themes.

Highly prevalent, multifactorial and overlapping in nature

HCPs acknowledged that DFV is a complex and significant issue in our setting. One respondent stressed that it is still very much considered as a hidden issue. Several of the HCPs commented that the women are often subjected to different forms of violence.

“This is quite hidden issue in our society and women do not talk about this issue simply. Last year, we conducted research, where we found that more than 50% of women were victims of violence. Based on our study, we can assume that this is highly prevalent.” [HCP 01]

It was felt that the current societal system placed men above women, and this was considered as one of the important factors for DFV. Another respondent supported this and added a lack of education as another contributing factor for DFV.

“A woman has to behave according to the direction of her father-in-law, her father, her umm… husband…and next is definitely illiteracy…” [HCP 07]

“Like I have already said, because of pressure from her mother-in-law (MIL) to have son, a woman needs to get pregnant again and again, her husband also thinks in the same way and there are cases when MIL has beaten her daughter-in-law because she does not work properly.” [HCP 06]

Violence remains undisclosed, unasked and unshared

In a male-dominated society of Nepal, DFV is often identified as a common family matter and as such, this violence although condoned can also be normalised. HCPs also believed that some forms of violence were common and probably had been experienced by all. Furthermore, they believed reporting every form of violence might lead to broken relationships. Some participants expressed these sentiments as follows,

“It is not like that there is no violence…”, “It is present in everyone's family….” and “Violence one or two times is persistent in majority of us”.

Another cultural norm is the belief that violence between a husband and wife is a private matter and should not be disclosed with others unless it turns out be a severe issue.

“Taking those minor things directly to the police administration or calling them, asking for support in Maiti Nepal [support organisation] can break the relationship. I feel that is one of the important issues.” [HCP 03]

In the hospital where the research was conducted, there was no provision of routine antenatal enquiry for DFV. Therefore, without the routine provision of DFV enquiry by nurses or doctors, women accessing BPKIHS for their pregnancy care would not be offered an opportunity to reveal their history of violence.

“At the time of ANC, while doing counselling we do not routinely ask about this problem. It has not yet become our part of care.” [HCP 01]

“…we have not seen such types of cases. It must be because we do not ask them. We do not have that facility and we do not ask them. There is no provision for asking anything related to violence …” [HCP 06]

Addressing DFV at different levels

During interviews, HCPs did acknowledge Nepal government’s current and ongoing commitment towards addressing DFV and securing a violence free life for women. At the time of the research, BPKIHS did not have OCMC, although the hospital management was lobbying with the government for its establishment. At the time the article was written, only rape victims presenting to the emergency department were referred to the police. The police were responsible for arranging for the medico-legal examination of victims and notifying the hospital’s authorities. HCPs expressed concerns that after disclosure of abuse, the issues of social rehabilitation might arise. HCPs were concerned as there was a lack of support organisations available to provide ongoing support to the women, There was a general lack of awareness among the staff that for some women providing the space to talk and offering advice and support by HCPs may in itself be considered helpful.

“In such cases [separation from family], where can we give security to her [victim of violence]? In which place we can keep her? We do not have such type of organisations. We just talk. . . .” [HCP 05]

Domain 2: Reflection of the program and its contents

Intervention participants and HCPs were asked to comment on how they perceived the different components of the intervention. Most of the participants expressed many benefits associated with the intervention, although some did express some barriers in adopting the intervention into their daily practice. The following two themes discuss these findings.

Impact of intervention on women’s lives

Data from HCPs and women provided a nuanced and deeper understanding of some important and meaningful impacts of the intervention, which are summarised under the following two subthemes.

A relationship based on trust. Most of the women reported that the counsellor made them feel comfortable, displayed empathy and respect towards them, and spent time with them. They highlighted that this relationship of trust acted as a strong foundation in promoting their self-empowerment. Some women even verbalised that they felt they had actually found a friend in the counsellor. Women perceived the counselling session to be a safe and contained place where they felt safe to open up about their personal emotions, their concerns and experiences. The person-centred approach adopted during the counselling session allowed women to express their immediate concerns and motivated those unwilling to share and express openly.

“I felt I had the confidence to come forward and express oneself. I felt relaxed and relieved.” [Woman, SR69]

“Having discussions in a separate place in a confidential manner, I liked it. I liked getting advice and suggestions. We were taught according to our needs, so it was good.” [Woman, NR63]

Feeling empowered, supported and valued. Participants appreciated the proactive enquiry from the counsellor, which they considered promoted information sharing. They valued this approach as they had never been asked about such sensitive issues before.

“I liked it as I was asked alone. Nobody has ever asked about such things. I always expect somebody to ask me such things. You asked, I felt really happy. I got one-to-one support.” [Woman, CL139]

“…we could say yes because we were asked. If we were not asked, we would not have known anything.” [Woman, NB136]

The majority of women were pleased to learn how to respond to DFV and found the advice offered by the counsellor as useful including “safety behaviours”, “support services”, and “strengthening social support”. Though there was variation in the preferences for the particular topic areas among participants, they all valued the individualised approach adopted by the counsellor. Participants expressed that the intervention helped them by promoting their capacity for self-enhancement and adopt strategies to keep themselves safe and healthy in future.

“I can share [the information related to conflict with in-laws] openly with my husband. I felt happy, developed courage. I was unable to speak initially. Now, my relationship with my husband has improved. [My] self-efficacy has enhanced.” [Woman, SD99]

“There was important information such as keeping documents and money safely. I have now kept my and my children’s copy of certificates at my parents' house as well.” [Woman, NP66]

HCPs further highlighted that providing education to women can be a cost-effective strategy as they can act as change agents by transmitting their learning to others, especially to other female family members and friends.

“They can share the information they have known with other daughters, daughters-in-law or their relatives or someone in need in their village or in neighbourhood. If needed, they can give the numbers.” [HCP 05]

The majority of participants expressed feeling reassured with a sense of continued support when they were provided with the contact details of the counsellor.

“Even if they cannot come on their own, by providing the contact numbers, they can decrease their emotional feeling to some extent.” [HCP 05]

Most of the participants verbalised that the booklet was easy to use, and the illustrations helped them to understand the content. Some of the common phrases used by the participants to explain the booklet was “easily understandable”, “simple language”, “comprehensive”, “good illustrations” and “illustrations complemented the text”. The feature of the booklet that women seemed to appreciate the most was the promotion of self-learning, and the opportunity to share it with others who are interested in learning about DFV.

“I understood a number of things after reading the book on my own.” [Woman, BS74]

“There were lots of information that I did not know earlier. I read that booklet repeatedly. Knowing simple tips regarding how to get rid of stress has really helped me a lot.”[Woman, CL139]

“Phone numbers included in the booklet can be shared with others as well. Once, I gave the number of police station to one of my friends who said that her husband beat her when he was drunk.” [Woman, NR63]

Perceived barriers to the intervention implementation

Despite the positivity towards the feasibility of the intervention occurring within a healthcare setting, some participants expressed some practicability issues related to the intervention. For instance, HCPs were circumspect about the provision of contact details of support services as this might lead to over reporting of the incidents of DFV which could result in escalation of broken family relationships. Similarly, four out of seven HCPs were worried about the potential safety related threats associated with the disclosure of DFV. Although, the DFV enquiry was always made in a private place, some women were concerned that they might face an interrogation from their family members about what were they asked in the clinic by the HCPs. Hence, family awareness of discussing violence with others could have negative repercussions.

“Family members might force her to tell why she had been taken inside, what she was asked. Oh, you have gone [disclose information to HCP] no? Did your organisation do anything? What did that organisation do? Telling these things, the woman might be re-victimised and one thing is there will be discrimination.” [HCP 06]

One participant was concerned that disclosing everything to HCPs might cause problem in future.

“I have told you everything trusting you, but sometimes get scared that it might cause some bad impacts in future.” [Woman, DK100]

Whilst most women acknowledged the booklet as a valuable learning resource, some participants felt the booklet was difficult to read because of the volume of content, and the small font and pictures contained within it. Another barrier highlighted by some women was ‘time’; they felt they were just too busy with their day-to-day activities to use the booklet regularly.

“Though the book includes information that was previously unknown, we do not have much leisure time to read the book.” [Woman, LR39]

Some barriers when using the phone as expressed by participants were “poor network”, “lost the number”, “not always feasible” and “hard to talk about sensitive issues over the phone”. Indeed, this was also raised by one HCP who specifically mentioned that contacting women via telephone or expecting them to make contact by telephone should not be the preferred method, as it did not allow for the face-to-face therapeutic communication between the counsellor and the woman, and can lead to feelings of insecurity.

“Rather than having telephone conversation, if we can meet her personally for interview, then it would be more effective, or we can talk a little more, we can guess from her looks as well.” [HCP 05]

“It is not always easy and feasible to discuss about family related matters over the phone.” [Woman, MC135]

Furthermore, during pregnancy, participants’ commented that their immediate needs were related to pregnancy and childbirth and they wanted to focus on the future and try to put their experiences of DFV behind them.

“It’s not easy to leave him. I am scared that my child's future will be threatened.” [Woman, DK100]

Domain 3: Recommendations for improving the intervention in the future

As the discussion turned to how best to implement the intervention in future, women and HCPs offered some ideas for its improvement and continuation. It was evident that the participants appreciated the comprehensive nature of the intervention; however, they presented some clear ideas on how the intervention could be improved, which are presented in the following four themes.

Expanding the reach of the program

Participants suggested extending the program into other health settings to address the issue of accessibility of the current program as only those women visiting BPKIHS had access to the program. It was thought that advertising the service widely through the hospital would be an excellent strategy to increase the uptake of the service by a larger cohort of people.

“As this study was done in a single setting, many women who do not visit this particular health facility are not included in the study. We are aware to some extent, that is why we are here, but what about others who are not allowed to seek health service?” [Woman, YK01]

Offering a continued delivery of the service in the health facility was desired by most of the participants. Indeed, some women also made recommendations about including non-pregnant women in the intervention. Few women (n = 3) suggested distributing the booklet to a wider network could help those who are unable to or do not want to come to health centres.

Embedding the intervention into routine health care

The majority of the HCPs were in favour of the integration of the DFV package into routine health care or PMTCT counselling service. They felt this as a cost effective way to benefit a large proportion of women in dealing with DFV. However, a nurse in-charge was not supportive of the idea of integration; she believed victims of DFV have varied needs and expectations and therefore, they require specialised support, which should be dealt separately from routine care.

“The program is different in itself, otherwise integration can also be possible. At first, listening too much information at a time they [women] might not feel [interested]. They may not feel like saying about these things, so in that case I feel it would be good to have different program.” [HCP 06]

Committed staff, sufficient resources and supportive management

HCPs recognised the importance of offering support to women experiencing DFV, and appreciated the intervention and expressed a willingness to continue with the program. However, they firmly asserted that for its successful implementation, they required an extra consultation room as well as trained personnel.

“We need a separate counsellor, a separate room to deliver the intervention. It will be difficult to deliver in the existing infrastructure.” [HCP 04]

HCPs stressed that initiating a program is not enough, what is important is a commitment to the continuation of the program. The success of the program is dependent upon knowledgeable and committed staff and continual support from senior management.

“Initiating a program is not just enough. There should be integration, after conducting such program there is minimal follow-up to assure that the actions are being implemented as planned.” [HCP 05]

HCPs highlighted several factors for improving the motivation among staff and the success of the program, which include appropriate workload and protected time for initial and continuation of training. All HCPs felt that collaboration with stakeholders at administrative, local, district and national level was also vital to the implementation of DFV program. Regular supportive supervision to staff were suggested by some HCPs to allow for discussing gaps in knowledge and developing strategies to implement the program efficiently.

“To start immediately, we need a willingness among staff. Starting from HOD [Head of Department], all higher authorities need to be involved. If this can be done, there is no thing that it [the intervention] cannot be done.” [HCP 05]

Adoption of different modalities of care

DFV is a complex issue and addressing it requires multi-dimensional and multi-sectoral health interventions. Participants suggested several recommendations for modifying the program and adopting new strategies, which are grouped under the following two subthemes.

Changing the structure of the program. Both HCPs and women indicated that there should be multiple and ongoing support sessions as they believed having a regular interaction facilitates disclosure and greater retention of the content taught.

“…spending some time together or had there been multiple visits, then more issues might have been unfolded, because in one single visit, not everything will come out.” [HCP 04]

“There can be some people who are reluctant to disclose at first and will disclose later only. If meeting can be made time and again, there will be easiness in sharing own feeling.” [Woman, KR61]

Some of the participants recommended group teaching and sharing and role-play, as they believed such approaches promote disclosure and encourage a deeper and active engagement from women.

“Role-plays in a group would be helpful to make us understand the matter easily.” [Woman, AB36]

“…involving victims of violence in a group and providing counselling. For example, when I said what I had felt, others may also say that these things have also happened to me.” [HCP 06]

One clinician suggested adopting a shared care model [General Practitioner (GP) or/and Midwifery care model] could be a viable strategy in distributing the workload, and such a model might help in ensuring the best quality of care to those seeking care.

“It is not necessary that every pregnant woman is examined by a gynaecologist or obstetrician. Even in abroad, midwives look after them or they are examined by GP and only high-risk cases are referred to us. If this can be done, we will have decreased patient load and they [pregnant women] will also receive adequate time.” [HCP 04]

Holistic approach in addressing DFV. HCPs as well as women believed that awareness raising at an individual level is not sufficient to deal DFV effectively. They suggested family/husband involvement for better and effective dealing with the issue.

“These days everyone knows about violence, but just knowing the violence does not mean that change lies on one's hand.” [Woman, CC94]

“I do not know how this problem can be solved. It is not possible to change family members on our own. Some of the elderly are uneducated and it is difficult to make them understand.” [Woman, NR63]

“At the same time, we need to provide education to the family. It is essential to inform those perpetrators that doing such things is wrong.” [HCP 01]

A small proportion of women felt that contextual factors, such as household and parenting responsibilities, family interference and expectations limited their attendance and adherence to the intervention. As a potential solution to this, they proposed home-based counselling service.

“Please continue this program. It would be better if villages are visited and help is provided to the victims of violence. For those who do not come to hospital and stay at home, even providing them with this booklet would be helpful.” [Woman, SR96]

A peer education model was also proposed, believing that peer involvement would ensure that the women would receive help and support from a person they know and at a place that they are familiar with.

“Teaching someone and asking her to teach others as well can help many to learn. Giving one or two extra books and asking that person to provide the booklet to other one or two people that she knows.” [Woman, NB136]

“Providing awareness in the community that the information should be shared openly would make many to understand the problem. If the program is conducted by including some active women from the community, it would be more effective.” [Woman, BR130]

From the interviews, it was evident that women understood the complexity of the problem and therefore believed multiple strategies were required to respond to the problem and meet the individual needs of the women and their families.

Discussion

Qualitative exploration of participants’ feelings added valuable insights to the design and effectiveness of a health sector based psychosocial intervention trialled in a resource-constrained setting. This study revealed both the strengths and weaknesses of several components of the intervention and identified the most useful and relevant outcomes for the participants. Results of this study can be used as a reference for developing and implementing a nurse-led intervention in addressing DFV in LMICs.

HCPs perceived DFV as a significant problem and reflected on the social drivers, such as patriarchal norms and illiteracy, behind such violence. Similar findings were reported in other studies from Nepal [2, 9]. Participants believed the intervention to be an empowering, easy and beneficial process. A supportive and therapeutic relationship between the women and HCPs facilitated disclosure and the exploration of violence; this was supported by findings from other studies [28, 29]. This uninhibited expression of oneself led to an increase in confidence, self-esteem and knowledge among women. Women further expressed a better ability to adopt safety strategies, seek social support and cope with mental consequences of DFV, similar to another study [22]. While participants acknowledged the use of an individualised approach in relation to a woman’s circumstances and varying informational needs [30] and reported its beneficial effects, the wider literature showed the short-term effects of such counselling intervention [14, 31]. Hence, studies with longer follow-up are recommended to conclude about the sustained effects of the counselling-based intervention. Some participants reported practicability issues in relation to regular use of the booklet and accessing and making the telephone call, as they felt they have other day-to-day family commitments to deal with rather than DFV. Therefore, it is advised to consider alternative method of information sharing in further studies.

For complex issues such as DFV, a one-size-fits-all approach usually does not work, as different people have different needs [32]. As a multitude of factors beyond the individual level influence DFV, participants expressed a need of adopting a holistic approach reaching across the relational, community and organisational levels of the social ecology [33]. Participants in this study proposed some strategies such as home-based counselling, husband involvement and peer involvement for improving response against DFV. Though home-based counselling and peer involvement have shown beneficial impacts in supporting victims and helping them to utilise support services [34], there were differing perspectives on the involvement of husband during counselling [35]. Particularly, in a patriarchal society such as Nepal, involving husband in the counselling might actually escalate the risk of future violence and isolate the woman even further. Therefore, it is suggested that involving husbands should be considered as an adjunct to individual therapy and couple counselling should be directed towards discussions around gendered roles, healthy relationships and responsible parenthood rather than directly discussing about DFV [35]. In addition, such approaches have been tested in developed countries, and thus, may not truly reflect the developing context. Hence, it is advisable to continually develop and evaluate context-specific interventions for addressing DFV in LMICs.

In the current study, participants also suggested delivering the intervention through multiple sessions; however, current literature indicates that the greatest improvements occur during the initial days of the intervention and decrease over time [36]. Considering the time and resource constraints, and evidence from past studies demonstrating the significant effects of single session therapy (SST) in improving the mental health and safety behaviours of abused women [37, 38], SST is considered a pragmatic and the best option. In addition, interventions requiring multiple interactions with women was pointed out as an important reason for high drop-out rates [39] and low attendance rates were seen in subsequent sessions [14, 40].

Screening in the antenatal period would provide an opportunity in creating awareness regarding potential causes and effects of DFV, which is crucial to protect the survivors and hold perpetrators accountable. Although screening at an ANC clinic has been significantly linked to increased identification of victims of DFV [40, 41], screening alone does not necessarily help victims to access services [16]. In the excerpts provided in the first domain in this study, it was evident that HCPs considered themselves unprepared to challenge the existing norms supporting violence and take action to help the victims of DFV. However, appropriate and regular training will help HCPs to develop communication skills that will help them to empower women to disclose their experiences of DFV openly and take appropriate actions to provide support and manage the consequences of DFV [8, 30]. Training of HCPs should include issues such as understanding dynamics of a violent relationship and socio-cultural drivers of DFV, validating women’s experiences, screening and dealing with barriers faced during screening, maintaining information regarding community resources and assisting victims with appropriate referrals [42, 43].

In agreement with previous studies, competing demands, time constraints and lack of sufficient resources were mentioned as the hindering factors for delivering DFV interventions in healthcare settings [28, 29]. System level changes such as training of HCPs, staff commitment, institutional support, onsite support services and effective collaboration with local stakeholders involved in providing support services are important for delivering continual and effective service to victims of DFV [40, 43, 44]. Considering the social stigma related to seeking help from DFV services and minimal funding in this area [8, 10], integrating DFV program into routine ANC and/or PMTCT counselling services can be a potential cost-effective strategy to improve response mechanisms against DFV in resource-constrained settings like Nepal. Such integrated approach of service delivery has been recommended in literature as well [13, 41].

Methodological considerations

The main strength of this study is seeking feedback from all participants, which enabled a broader capture of participants’ views and ensured general representation of the overall sample. Throughout the process, measures to ensure trustworthiness, essential for others to judge the value of the study, have been taken [27]. Despite being a novel study contributing to bridge the knowledge gaps, it must be acknowledged that this study has some limitations. Due to the safety concerns, it was not possible to capture the reasons for discontinuation of the study by the participants (7 women at the first follow-up and 19 at the second follow-up were lost to follow-up). However, these drop-out rates are comparable with similar research [14, 40] and the intervention appeared to be effective in addressing important needs of the victims. Furthermore, as this study included only women accessing one health facility for their antenatal check-up, it did not represent the overall expectations and attitudes of women visiting other health facilities. As a consequence, the findings of the study may be transferrable to similar groups but they cannot be generalised.

Conclusion

This study identified elements of the intervention that participants regarded as either beneficial or problematic, thereby providing insights on how the intervention may be improved for future use. Disclosure of violence and seeking support services was facilitated by a relationship of trust between service users and HCPs. The intervention was perceived as an innovative and effective approach in addressing the immediate needs of victims of DFV, however, for effective dealing with DFV, participants suggested expanding the intervention to a wider setting and delivering it through multiple sessions. Integration of the intervention within routine ANC package was proposed as a potential strategy to improve the accessibility and sustainability of the intervention. Overall, this study emphasised the need for education and organisational support to create a supportive environment to facilitate engagement and knowledge among victims of DFV.

This supporting file includes the COREQ checklist of the present study.

(DOCX)

Click here for additional data file.

This supporting file includes the interview schedule for intervention participants and health care providers.

(DOCX)

Click here for additional data file.

18 Oct 2019

PONE-D-19-22252

‘We don’t see because we don’t ask’: qualitative exploration of service users’ and health professionals’ views regarding a psycho-social intervention targeting pregnant women experiencing domestic and family violence

PLOS ONE

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Thank you for your important work on violence against women in Nepal. The article has been independently critiqued by three reviewers who have provided feedback below. In particular, the authors are asked to provide a more critical appraoch to the intervention (feasibility, barriers, efficacy, etc.) and to clarify some of your methodologies.

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Reviewer #3: Partly

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Reviewer #3: No

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Reviewer #1: Overall, the study is an important contribution to the literature and to practice of domestic violence prevention. A few revisions are recommended below for consideration to enhance the study’s influence.

1. The abstract mentions that the study will assess feasibility and efficacy. However, both need additional articulation as to what realms of both of these issues the qualitative study was meant to assess and how do the findings relate to those domains. For example, feasibilty could be assessed in a much broader realm than what is presented. The same for the efficacy results. What were the primary outcomes and how did the study reach or not reach those goals as ascertained through the qualitative assessment. While this is an embedded qualitative study, there were most likely primary outcomes for feasibility and efficicacy that would be helpful to state up front and assess the accomplishment of the study against those expectations.

2. Needed, especially in the discussion but also in the introduction is a more critical assessment of the role of screening in settings where services are perceived to be lacking or ineffective. There is growing programming in Nepal from the government and from local and international NGOs that deal with this topic, but still the services were percevied to be to lacking. More contextualization of what is available versus what is perceived to be available and effective would help the reader to ascertain this disconnect.

3. Similarly, given the perceived lack of services, and possibility of actual lack of services, it would be helpful to have a more indepth discussion of screening and referral in such an environment. This has programmatic implications but also ethical ones that would be helpful to understand in more detail.

4. The discussion has a strong bend toward literature that supports the study’s findings. A more critical assessment of the literature would useful to help situation the study’s findings in the broader programmatic and research literatures.

5. Additionally, a stronger critique of a one-session intervention is needed. The respondents for the most part seemed to suggest that more is better and that is often the case with exposure to interventions, including literature supporting interventions for health sector based violence prevention. While the intervention is described as theory based, it would be helpful to understand what kind of change was anticipated from a one session counseling session, that the respondents seemed to indicate was useful, but not sufficient to change practices that are both normative and perpetrated by others.

6. The health providers mentioned the importance of the topic, but also clearly indicated the fear of marriage dissolution. This speaks to the strong norms underpinning the family as a key unit as well as the fear of massive over-reporting, which is not likely the case given statistics the world over that a vast minority of violence survivors seek formal help, especially through the health sector. Additional consideration of these perceptions would be helfpul to understand what type of training and support is needed at the facilitator level to make screening and referral successful.

7. The health providers mentioned several institutional barries to making this type of programming work. Additional consideration as to the feasibility of this type of intervention with limited staffing, limited time, etc in a lower income setting. While there is a move to have one stop centers in hospitals, how widespread is this and how likely is continued funding for the staffing and infrastructure needed to sustain the program as sustainability is a key theme of the analysis.

8. The short duration of the interviews with survivors and the lack of quotes that showed how survivors actually used the brochures or the counseling in their real life suggests a lack of depth of the impact. Is there evidence that represents more than general perceptions of utility and benefit? This would be helpful evidence to see impact/efficacy beyong more general perceptions of utility.

9. The study particpants represent individuals who in large part participated in the program. A significant number did not and there is no information about those individuals. In terms of feasibility and efficacy, what does the non participant/lack of follow up suggest?

Reviewer #2: Thank you for the opportunity to review this manuscript - it addresses a very important topic. The research design for the study was appropriate and there is evidence of a robustly undertaken study. The study was well contextualised in the context of DFV in LIMC and the activities of the intervention was useful. I have the following observations for the authors to improve the manuscript:

Abstract

In the abstract (conclusion) we are informed for the first time that the intervention was an antenatal intervention. this information would have been useful to have earlier in the abstract. The 'introduction' would be an appropriate place.

It would be useful for terminology to be consistent throughout. The term 'abuse' is used interchangeably with 'violence'.

Data Collection

Data were collected from the women at 4-6 weeks after the intervention and gain 6 weeks post birth. This indicates that there was some kind of longitudinal data collection. On lines 96-97 it is noted that “verbal and non-erbal cues from the participants were noted down on paper as well”. This would not be for all participants as some were interviewed by telephone. Clarity needed. How were these observations used as they are not discussed in the analysis section?

Data collection at 2 time points with the women allows for some investigation of whether or not their views changed over time, and more nuanced understanding of how they used the information provided across time. The analysis, however, makes no distinction between data that were collected shortly after the intervention and post-birth. It would also be interesting to know whether the same questions were asked at each time point or if they changed and the reason for either. For a longitudinal data collection, I would have expected to see an analysis with a temporal component.

Data Analysis

The reference that is provided for the data analysis is Braun and Clarke, yet the description of the process that was undertaken does not reflect the 6 steps that Braun and Clarke identify. Additionally, the description of data analysis does not appear to reflect steps that were taken in the order they were undertaken. It is also noted that “the final codebook was developed through progressive iterations with other authors” (lines 103-104). This reads as if the emerging data did not impact on the codebook. Taken to its logical conclusion, this could suggest that data were ‘moulded’ to fit the codebook and not vice versa. I’m certain that this was not what the authors intended. Greater clarity around data analysis is needed.

Trustworthiness/Rigour

The reference provided for Lincoln and Guba is Cohen, Crabtree, yet the weblink does not appear to have Cohen & Crabtree on the site (Lincoln and Guba are, but I could not see Cohen & Crabtree). Clarification needed. Additionally Lincoln and Guba use the term 'confirmability' not 'conformability' - clarification needed.

Results

Domain 2 has a very nice lead in sentence about who was asked about the issues to be discussed. In Domain 1, understanding that it was just HCPs who were asked about DFV per se is less clear. A sentence similar to Domain 2 would be very useful.

Discussion

On page 25 consideration is given to including husbands in the counselling sessions with the women. I would urge caution here given the large literature about the dangers to women in doing this, or at the very least, include the suggestion but with the caveat around the literature on the potential dangers and inappropriateness of such an approach in the literature.

General comments

It would be useful for more details about the counsellor(s) to be included in the manuscript. It is not until line 471 that the reader is told that the intervention is 'nurse-led'. I have taken this to mean that the 'counsellor' is a nurse? This needs explanation and incorporation earlier in the manuscript. It would also be important to include the level of understanding of the counsellor of the dynamics of violent relationships, particularly bearing in mind the body of literature that describes the inappropriate response that many women who are experiencing DFV receive from counsellors who do not have this understanding.

The quotes often appear a bit disconnected from the text that introduces and describes them. Consider interspersing your quotes rather than presenting them in a block at the end of each section.

On page 12 (lines 220-221) it is noted that ……[the approach] ………helped them [women] to consider adopting a change in their lives”. I’m sure it is just the way it is written, but it reads as if the onus if on the women to change rather than the perpetrator to end his use of violence.

Page 16 (among others) mention is made of making contact by telephone (line 298). The authors do note that the WHO ethical and safety recommendations for violence related research were utilised, but it might be worthwhile making a specific comment about how you were able to be assured that the woman was safe, or her safety would not be compromised, if you were making contact by telephone.

Page 21 – lines 411 – 413 provides a brief description of s shared care model. Please consider including within that text that the clinicians need to understand the dynamics of a violent relationship – having clinical knowledge is insufficient.

Page 21 (lines 423-424) reference is made to an intervention that addresses perpetrators. Whilst this may be a worthwhile intervention it is a very different intervention to what was piloted. This needs to be recognised.

Typographical errors and errata

Page 4 – delete ‘the’ between ‘about’ and ‘DFV’

Page 4 - change ‘practicing’ to ‘practising’

Page 5 – delete comma after ‘Besides’

Page 9 – add ‘s’ to ‘explanation’

Page 12 – change’ spend’ to ‘spent’

Page 18 – the term ‘participant’ is used as a descriptor for a quote. Change?

Page 20 – it is noted (line 391) that addressing DFV required ‘multi-dimensional health interventions’ Not only do interventions need to be multi-dimensional, they need to be multi-sectoral. Include?

Page 25 – change ‘setting’ to ‘settings’ (line 513)

Awkward expression:

Lines 143 – 144: “Data analysis materialised a number of themes and subthemes”

Line 494 – change “punish the perpetrators” to “hold perpetrators to account”

Lines 505-507 – re-word “Similar to the current finding……….support services”

Reviewer #3: This paper is in an area of great importance because there is a dearth of interventions for IPV especially in low income countries. Process evaluations of trials of interventions are vital and not done enough in research. There are several areas for improvement in the manuscript detailed below.

Abstract

It is not clear what the research questions are or specific objectives. The themes are a bit difficult to interpret

Introduction is a good background and the objectives are clear here.

Methods. It is not clear when the second interviews were done in relation to the intervention as women were recruited up to 34 weeks?

how many people in total were in the intervention group- was it 63?

what was the pool of HCPs that the 7 were selected from and how were they able to provide the most pertinent information?

What were the interview questions?

Were the women and HCPs analysed together? and why?

Please spell out the Braun and Clarke method in more detail.

Results

It is confusing the domains and then the themes and they are not reflected in the abstract clearly. Further the materail needs to be synthesised more there are too many themes. A further synthesis would strengthen the analysis.

The themes are very descriptive, which does not match quality thematic analyses. It appears that the domains might reflect direct interview questions which has resulted in this very descriptive level analyses?

Why is the first domain only from HCPs?

Please remove some of the aconyms

In the second domain it would be good to get a sense of the strength of the themes- some women, most women....

p12 it is not helpful to discuss the quantitative findings as they are not presented here.

Some of the quotes are very powerful but sometimes the headings for the subthemes don't match the quotes e.g. new and positive learning experience starts with the value of being asked alone and the feeling empowered section suddently has barriers using the phone?

Discussion

The discussion repeats the findings quite a lot rather than summarising and the conclusion is not helpful as we dont have the quantitatve results.

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Reviewer #1: No

Reviewer #2: Yes: Prof Colleen Fisher

Reviewer #3: No

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21 Nov 2019

Response to reviewers’ comments

I would like to extend my sincere thanks to the editor and the reviewers for careful and thorough reading of this manuscript and for their thoughtful comments and constructive suggestions. I have revised the manuscript in the light of the provided feedback and comments and highlighted text indicates the changes made. Responses to their specific comments/suggestions/queries are as follows:

[note: C: Comment, R: Response]

S.N. Editor Comments to Author: Responses

C1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

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R1 Thank you for your informative feedback. The necessary amendment has been made.

C2. We suggest you thoroughly copyedit your manuscript for language usage, spelling, and grammar. If you do not know anyone who can help you do this, you may wish to consider employing a professional scientific editing service.

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R2. The research team consisted of person who are native English speakers and the manuscript has been thoroughly reviewed and revised by them. In addition, language usage, spelling and grammar were thoroughly edited by two colleagues, who are native English speakers and have sound knowledge in research.

1. Nicole McDonald, Project Manager, My Health for Life

2. Stephanie Zietek, Senior Research Officer, Women’s Wellness Research Program

All the requested information/files have been uploaded.

C3. Please ensure you have included the registration number for the clinical trial referenced in the manuscript.

R3: Thank you. The registration number has been included in the manuscript. (Page no. 7, line no: 125-126)

C4. We note that you have included your manuscript title page as a separate, 'Other' file.

Please ensure that you include a title page within your main document. You should list all authors and all affiliations as per our author instructions and clearly indicate the corresponding author.

R4.Thank you. Title page has been included in a main document and it aligns with the manuscript guidelines (Page 1)

Responses to reviewers’ comments

A. Reviewer #1: Overall, the study is an important contribution to the literature and to practice of domestic violence prevention. A few revisions are recommended below for consideration to enhance the study’s influence.

C1. The abstract mentions that the study will assess feasibility and efficacy. However, both need additional articulation as to what realms of both of these issues the qualitative study was meant to assess and how do the findings relate to those domains. For example, feasibility could be assessed in a much broader realm than what is presented. The same for the efficacy results. What were the primary outcomes and how did the study reach or not reach those goals as ascertained through the qualitative assessment? While this is an embedded qualitative study, there were most likely primary outcomes for feasibility and efficacy that would be helpful to state up front and assess the accomplishment of the study against those expectations. R1. Thank you for your comment. This was a nested qualitative study and the main aim of this study was to explore the experiences of participants regarding the intervention and their perceived impacts. Objectives have now been written in a simpler and clearer terms in the abstract section. (Page 2, line no 25-28)

C2. Needed, especially in the discussion but also in the introduction is a more critical assessment of the role of screening in settings where services are perceived to be lacking or ineffective. There is growing programming in Nepal from the government and from local and international NGOs that deal with this topic, but still the services were perceived to be to lacking. More contextualization of what is available versus what is perceived to be available and effective would help the reader to ascertain this disconnect.

R2. Thank you for your constructive feedback. A brief account of the ongoing programmes and efforts for addressing DFV in Nepal has been included in the introduction section. In addition, gaps or limitations of the current activities targeting DFV in Nepal are also highlighted. (Page 4: line no 59-75)

In the introduction and discussion section, role of screening in resource-constrained setting has been written. (Page 5, line no. 83-86 & Page 26, line no 544-548)

C3. Similarly, given the perceived lack of services, and possibility of actual lack of services, it would be helpful to have a more in-depth discussion of screening and referral in such an environment. This has programmatic implications but also ethical ones that would be helpful to understand in more detail.

R3.Thank you for your constructive feedback. A brief account of the ongoing programmes and efforts for addressing DFV in Nepal has been included in the introduction section of the paper. In addition, gaps or limitations of the current activities targeting DFV in Nepal are also highlighted. (Page 4: line no 59-75)

In the last 2 paragraphs of the discussion section, the measures to improve screening and referral in the study setting has been discussed and supported by literature. (Page no. 26-27, line no 544-568)

C4. The discussion has a strong bend toward literature that supports the study’s findings. A more critical assessment of the literature would be useful to help situation the study’s findings in the broader programmatic and research literatures.

R4. Thank you for your constructive feedback. Additional literature was reviewed and statements supporting the programmatic implications of the findings have now been added in the discussion section (Page 26-27, line no. 544-568)

C5. Additionally, a stronger critique of a one-session intervention is needed. The respondents for the most part seemed to suggest that more is better and that is often the case with exposure to interventions, including literature supporting interventions for health sector based violence prevention. While the intervention is described as theory based, it would be helpful to understand what kind of change was anticipated from a one session counseling session, that the respondents seemed to indicate was useful, but not sufficient to change practices that are both normative and perpetrated by others.

R5. Thank you for your feedback. Given the time and financial constraints, one session intervention was the only viable option and several articles have supported the use and effectiveness of single session therapy in addressing violence.

These points have been included in the discussion section (Page no: 26, line no. 536-543)

Furthermore, the objective of this intervention was to help victim understand that DFV is a problem and help is available against it and also help her develop strategies to cope with the negative consequences of violence. This intervention did not intend to change the gender and societal values and behaviours of perpetrators, for which, we definitely will need an intervention delivered in multiple sessions and over the long run.

C6. The health providers mentioned the importance of the topic, but also clearly indicated the fear of marriage dissolution. This speaks to the strong norms underpinning the family as a key unit as well as the fear of massive over-reporting, which is not likely the case given statistics the world over that a vast minority of violence survivors seek formal help, especially through the health sector. Additional consideration of these perceptions would be helpful to understand what type of training and support is needed at the facilitator level to make screening and referral successful.

R6. Thank you for your feedback.

The main things to be included while training HCPs to make screening and referral successful are now mentioned in the discussion section (Page no. 26-27, line no 551-557).

C7. The health providers mentioned several institutional barriers to making this type of programming work. Additional consideration as to the feasibility of this type of intervention with limited staffing, limited time, etc in a lower income setting. While there is a move to have one stop centers in hospitals, how widespread is this and how likely is continued funding for the staffing and infrastructure needed to sustain the program as sustainability is a key theme of the analysis.

R7. The situation analysis of availability and performance of OCMCs is included in the introduction section (Page 4, line no 60-73).

Recommendations from HCPs and women regarding approaches in making the program sustainable have been discussed in the discussion section (Page no: 26-27, line no: 544-568).

C8. The short duration of the interviews with survivors and the lack of quotes that showed how survivors actually used the brochures or the counselling in their real life suggests a lack of depth of the impact. Is there evidence that represents more than general perceptions of utility and benefit? This would be helpful evidence to see impact/efficacy beyond more general perceptions of utility.

R8. Thank you for your feedback. We do acknowledge the short duration of interviews with the participants. However, as the women were asked to provide their feedback about the intervention after they finished their quantitative follow-up assessments, it was not feasible to have long in-depth interviews with them. Furthermore, we only intended to seek their feedback regarding strengths and weakness of the intervention only.

Quotes reflecting the impact/ benefits of the intervention as perceived by the participants are added under the theme “Impact of intervention on women’s lives”. (Page no 15-16, line no. 308-314) & (Page no: 17, line no: 333-338)

C9. The study participants represent individuals who in large part participated in the program. A significant number did not and there is no information about those individuals. In terms of feasibility and efficacy, what does the non participant/lack of follow up suggest?

R9. Although there was a 10% of participant drop-out in first assessment and about 27% in second follow-up assessment, this was comparable with similar research. This information has been added to the discussion [Page no. 27, line no. 575-577]. It does indicate that there are some for whom the program was not feasible or acceptable. However, due to the safety of the women, we were unable to capture reasons for their loss to follow-up. As such this is listed as a limitation of the study in lines 575-579 on page 27-28. However, the program does still appear to be effective for the women who were able to be captured and as such addresses important needs for them.

B. Reviewer #2: Thank you for the opportunity to review this manuscript - it addresses a very important topic. The research design for the study was appropriate and there is evidence of a robustly undertaken study. The study was well contextualised in the context of DFV in LIMC and the activities of the intervention was useful. I have the following observations for the authors to improve the manuscript:

C1. Abstract

In the abstract (conclusion) we are informed for the first time that the intervention was an antenatal intervention. this information would have been useful to have earlier in the abstract. The 'introduction' would be an appropriate place.

It would be useful for terminology to be consistent throughout. The term 'abuse' is used interchangeably with 'violence'.

R1. Thank you for the feedback.

To make it clear, the abstract has been rewritten and sentence explaining that the intervention was an antenatal intervention was added.

(Page 2, line no: 25-28)

Manuscript was read carefully, and the terminology ‘violence’ has been used throughout the manuscript to ensure consistency.

C2. Data Collection

Data were collected from the women at 4-6 weeks after the intervention and again 6 weeks post birth. This indicates that there was some kind of longitudinal data collection. On lines 96-97 it is noted that “verbal and non-verbal cues from the participants were noted down on paper as well”. This would not be for all participants as some were interviewed by telephone. Clarity needed. How were these observations used as they are not discussed in the analysis section?

Data collection at 2 time points with the women allows for some investigation of whether or not their views changed over time, and more nuanced understanding of how they used the information provided across time. The analysis, however, makes no distinction between data that were collected shortly after the intervention and post-birth. It would also be interesting to know whether the same questions were asked at each time point or if they changed and the reason for either. For a longitudinal data collection, I would have expected to see an analysis with a temporal component. Non-verbal cues were only collected from women who were interviewed in person. While these were initially examined, they did not contribute any additional information. As such, since this information was not included we have removed this line to help reduce confusion. (Page 8, line no: 150-151)

R2. The primary purpose of this study was not to observe changes in views over time. However, as you mentioned the temporal change could have been an interesting question to examine. As the same questions were asked at each time-point, an initial examination was made for differences in the themes for each time-point. This examination found no major differences by time-point and after discussion by the author team it was decided to present the data together as a whole piece. A sentence regarding this has been added to the data analysis section (Page 9, line no: 169-172).

C3. Data Analysis

The reference that is provided for the data analysis is Braun and Clarke, yet the description of the process that was undertaken does not reflect the 6 steps that Braun and Clarke identify. Additionally, the description of data analysis does not appear to reflect steps that were taken in the order they were undertaken. It is also noted that “the final codebook was developed through progressive iterations with other authors” (lines 103-104). This reads as if the emerging data did not impact on the codebook. Taken to its logical conclusion, this could suggest that data were ‘moulded’ to fit the codebook and not vice versa. I’m certain that this was not what the authors intended. Greater clarity around data analysis is needed.

R3. Thank you. Six phases of thematic analysis as suggested by Braun and Clarke is now mentioned in the analysis section. The codes were discussed iteratively with the research team. Codes were grouped into categories and potential themes were extracted. After several rounds of discussions with the research team, the themes were finalised and supporting excerpts extracted.

The data analysis section has been rewritten with further detail providing a deeper explanation of 6 steps of Braun and Clarke (Page no. 9, line no.: 154-172).

C4. Trustworthiness/Rigour

The reference provided for Lincoln and Guba is Cohen, Crabtree, yet the weblink does not appear to have Cohen & Crabtree on the site (Lincoln and Guba are, but I could not see Cohen & Crabtree). Clarification needed. Additionally, Lincoln and Guba use the term 'confirmability' not 'conformability' - clarification needed.

R4. Thank you for your comment.

Initially we have used the secondary source given by Cohen and Crabtree in their webpage. However, following feedback, reference has been changed to the original book Lincoln and Guba (Reference no. 26).

Sorry for the typographical error. The correct terminology ‘confirmability’ has now been written (Page 10, line no. 184).

C5. Results

Domain 2 has a very nice lead in sentence about who was asked about the issues to be discussed. In Domain 1, understanding that it was just HCPs who were asked about DFV per se is less clear. A sentence similar to Domain 2 would be very useful.

R5. Intervention participants were asked to provide answer to open-ended questions regarding strengths and weakness of the intervention, and any recommendation they might have during their follow-up assessments. At this point, it was not appropriate to ask about the participants’ views regarding DFV and its response mechanisms.

However, in-depth interviews were conducted with the HCPs and question regarding how they perceive the problem of DFV and the existing efforts to address were asked at first as it was deemed necessary to explore their views regarding DFV before asking them about their views regarding the piloted intervention.

Hence, Domain 1 included views expressed by HCPs only. A sentence has been added in the Methods: Data collection section (Page 8, line no 138-139) and a next sentence has been added in Results: domain 1 to make it clear (Page 11, line 211).

C6. Discussion

On page 25 consideration is given to including husbands in the counselling sessions with the women. I would urge caution here given the large literature about the dangers to women in doing this, or at the very least, include the suggestion but with the caveat around the literature on the potential dangers and inappropriateness of such an approach in the literature. R6.Thank you for your feedback.

This has been mentioned in the discussion section and supported by relevant literature (Page 25, line no 525-531).

C7. General comments

It would be useful for more details about the counsellor(s) to be included in the manuscript. It is not until line 471 that the reader is told that the intervention is 'nurse-led'. I have taken this to mean that the 'counsellor' is a nurse? This needs explanation and incorporation earlier in the manuscript. It would also be important to include the level of understanding of the counsellor of the dynamics of violent relationships, particularly bearing in mind the body of literature that describes the inappropriate response that many women who are experiencing DFV receive from counsellors who do not have this understanding.

R7. Thank you for your feedback.

The intervention was delivered by a trained nurse who has several years of experiences in working with victims of violence. Furthermore, the nurse had adhered to the intervention delivery guide to ensure consistency while delivering the intervention to all participants allocated to the intervention. This has been explained briefly in the introduction section (Page 5-6, line no. 93-99)

The detailed description about the research team including the intervention nurse is included in the protocol paper (Sapkota D, Baird K, Saito A, Rijal P, Pokharel R, Anderson D. Counselling-based psychosocial intervention to improve the mental health of abused pregnant women: a protocol for randomised controlled feasibility trial in a tertiary hospital in eastern Nepal. BMJ Open. 2019;9(4):e027436.)

C8. The quotes often appear a bit disconnected from the text that introduces and describes them. Consider interspersing your quotes rather than presenting them in a block at the end of each section.

R8. Thank you for your suggestion. We have tried to intersperse the quotes where feasible and appropriate (Page no 14-24). In some instances where findings are summarised in one or two sentences, in order to preserve the essence of the message we want to deliver, we have included the quotes at the end of that particular section only.

C9. On page 12 (lines 220-221) it is noted that ……[the approach] ………helped them [women] to consider adopting a change in their lives”. I’m sure it is just the way it is written, but it reads as if the onus if on the women to change rather than the perpetrator to end his use of violence.

R9. Thank you. The sentence has been restructured to make it clearer.

C10. Page 16 (among others) mention is made of making contact by telephone (line 298). The authors do note that the WHO ethical and safety recommendations for violence related research were utilised, but it might be worthwhile making a specific comment about how you were able to be assured that the woman was safe, or her safety would not be compromised, if you were making contact by telephone.

R10. Thank you. The statement focusing on strategy adopted to ensure safety to participant while making telephone call has been added in the methods section under sub heading Data Collection (Page 8, line no 145-148).

In the original manuscript, it was mentioned that the study was conducted in adherence to WHO’s ethical guidelines (Page 10, line no. 184-186). The approaches adopted to ensure safety and confidentiality to participants based on WHO ethical and safety recommendations for conducting intervention research on violence against women have been explained in detail in protocol paper. (Sapkota D, Baird K, Saito A, Rijal P, Pokharel R, Anderson D. Counselling-based psychosocial intervention to improve the mental health of abused pregnant women: a protocol for randomised controlled feasibility trial in a tertiary hospital in eastern Nepal. BMJ Open. 2019;9(4):e027436.)

C11. Page 21 – lines 411 – 413 provides a brief description of s shared care model. Please consider including within that text that the clinicians need to understand the dynamics of a violent relationship – having clinical knowledge is insufficient.

R11. Thank you for your comment.

In the discussion section, key issues that needs to be included while training HCPs on dealing with violence have been mentioned (Page 26-27, line no. 553-557).

C12. Page 21 (lines 423-424) reference is made to an intervention that addresses perpetrators. Whilst this may be a worthwhile intervention it is a very different intervention to what was piloted. This needs to be recognised.

R12. Thank you for your constructive feedback. This was based on participants’ feedback, where they recommended of having program for perpetrators as well. Based on this single comment only, we can’t recommend conducting DFV program for perpetrators.

Potential consequences of involving husband in counselling section has been discussed in brief in discussion section (Page 25, line no 525-531).

C13. Typographical errors and errata

Page 4 – delete ‘the’ between ‘about’ and ‘DFV’

Page 4 - change ‘practicing’ to ‘practising’

Page 5 – delete comma after ‘Besides’

Page 9 – add ‘s’ to ‘explanation’

Page 12 – change’ spend’ to ‘spent’

Page 18 – the term ‘participant’ is used as a descriptor for a quote. Change?

Page 20 – it is noted (line 391) that addressing DFV required ‘multi-dimensional health interventions’ Not only do interventions need to be multi-dimensional, they need to be multi-sectoral. Include?

Page 25 – change ‘setting’ to ‘settings’ (line 513)

R13. Thank you for pointing out these errors.

All mentioned typographical errors were addressed. In addition, the manuscript has been critically reviewed by authors and language and grammatical errors are now corrected.

C14. Awkward expression:

Lines 143 – 144: “Data analysis materialised a number of themes and subthemes”

Line 494 – change “punish the perpetrators” to “hold perpetrators to account”

Lines 505-507 – re-word “Similar to the current finding……….support services”

R14. Thank you for highlighting this.

Revisions were made to remove these highlighted awkward expressions.

C. Reviewer #3: This paper is in an area of great importance because there is a dearth of interventions for IPV especially in low income countries. Process evaluations of trials of interventions are vital and not done enough in research. There are several areas for improvement in the manuscript detailed below.

C1. Abstract

It is not clear what the research questions are or specific objectives. The themes are a bit difficult to interpret

R1. Thank you for your feedback. The objectives and results in the abstract have been rewritten to make it clearer (Page 2, line no: 25-28; 33-35).

C2. Introduction is a good background and the objectives are clear here.

R2. Thank you for the comment

C3. Methods. It is not clear when the second interviews were done in relation to the intervention as women were recruited up to 34 weeks?

How many people in total were in the intervention group- was it 63?

What was the pool of HCPs that the 7 were selected from and how were they able to provide the most pertinent information?

R3. Thank you for your comment. The second interviews were conducted at 4-6 weeks post-intervention and few women with 34 weeks of gestation were included in this study and they had delivered after 38 weeks of gestation, so having second interview with them was not an issue.

The number of women recruited was mentioned in the first line of results section (Page 10, line no. 197)

“A total of 63 women at the first follow-up and 51 women at the second follow-up, belonging to the intervention group, were asked about their views and opinions regarding the intervention.”

The characteristics of the HCPs included in the trial were mentioned in the first paragraph of results section (Page 11, line no 200-205).

C4. What were the interview questions?

R4. Thank you. Interview questions used for participants and health care providers were included in supplementary file 2.

C5. Were the women and HCPs analysed together? and why?

R5. Yes, women and HCPs were analysed together as most of the themes emerging from the data overlapped and while interpreting the findings, attempts were made to clarify which quotes belonged to which group of participants. For eg: ‘HCP’ was written if that quote was from health care providers and ‘Woman’ was written for the quotes extracted from interview with intervention participants.

C6. Please spell out the Braun and Clarke method in more detail.

R6. Analysis section has been rewritten based on the 6 steps of thematic analysis proposed by Braun and Clarke (Page no. 9, line no.: 154-172).

C7. Results

It is confusing the domains and then the themes and they are not reflected in the abstract clearly. Further the material needs to be synthesised more there are too many themes. A further synthesis would strengthen the analysis.

R7. Abstract has mentioned about the broad domains of the qualitative data analysis (Page 2, line no. 33-35). Key findings were presented in the result section.

Figure 1 illustrates domains, themes and subthemes generated from data analysis.

Thank you for your suggestion. Some of the subthemes were synthesized which we believed might have strengthened the analysis now (Page no. 15-20).

C8. The themes are very descriptive, which does not match quality thematic analyses. It appears that the domains might reflect direct interview questions which has resulted in this very descriptive level analyses?

R8. Thank you for your suggestion. This study aimed to explore the perceptions and experiences of intervention participants and HCPs regarding the intervention. So, themes reflecting this objective were identified and finalised after iterative discussion with the study authors.

C9. Why is the first domain only from HCPs?

R9. Intervention participants were asked to provide answer to open-ended questions regarding strengths and weakness of the intervention, and any recommendation they might have during their follow-up assessments. At this point, it was not appropriate to ask about the participants’ views regarding DFV and its response mechanisms. However, in-depth interviews were conducted with the HCPs and question regarding how they perceive the problem of DFV and the existing efforts to address were asked at first and it is deemed important to explore their views regarding DFV before asking them about their views regarding the piloted intervention.

A sentence has been added in the Methods: Data collection section (Page 8, line no 138-139) and a next sentence has been added in Results: domain 1 to make it clear (Page 11, line 211).

C10. Please remove some of the acronyms

R10. Acronyms are used as less as possible and are described in full form at the time of their first use.

C11. In the second domain it would be good to get a sense of the strength of the themes- some women, most women....

R11. Thank you, we have tried to provide a response where possible (Page 14-16)

C12. p12 it is not helpful to discuss the quantitative findings as they are not presented here.

R12. Thank you. The sentence has been restructured as suggested (Page 14, line no. 275).

C13. Some of the quotes are very powerful but sometimes the headings for the subthemes don't match the quotes e.g. new and positive learning experience starts with the value of being asked alone and the feeling empowered section suddenly has barriers using the phone?

R13. Thank you for your suggestion.

Some subthemes were merged to make them easy to understand (Page no. 15-21).

C14. Discussion

The discussion repeats the findings quite a lot rather than summarising and the conclusion is not helpful as we don’t have the quantitative results.

R14. Thank you for your comments.

The findings were discussed in brief before providing supporting or contradicting arguments based on other studies. Following your comments, the discussion section has been revised and discussed in more detail with reference to other literature (Page no. 24-27).

This study summarises the findings of qualitative analysis and conclusion is based on the qualitative findings. Quantitative findings of the study have also been analysed and support the qualitative findings (Manuscript based on quantitative findings is under preparation)

Submitted filename: Responses to reviewers_1711019.docx

Click here for additional data file.

8 Jan 2020

PONE-D-19-22252R1

‘We don’t see because we don’t ask’: qualitative exploration of service users’ and health professionals’ views regarding a psychosocial intervention targeting pregnant women experiencing domestic and family violence

PLOS ONE

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Reviewer #2: (No Response)

Reviewer #4: (No Response)

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Reviewer #4: Yes

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Reviewer #4: N/A

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Reviewer #4: Yes

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Reviewer #2: Thank you for addressing issues raised in the previous round of review. Upon re-reviewing the manuscript, however, I would like to raise issues that I feel still require further response.

There appears to be inconsistency in the stated aims of the research.

The abstract (lines 25-26) - "acceptability and the perceived impact of....[the intervention]

The introduction (lines 135-119) - "....perceived strengths and limitations of [the intervention] (described as 'objectives')

Finding - Line 382 - 'improvement and sustainability'. Although this is not an aim per se, it does highlight the inconsistency across the manuscript in what was being addressed through this particular study.

Clarity and consistency needed.

Other inconsistencies:

Line 133, reference is made to "the research nurse", yet line 139 refers to "Both interviewers'. It is unclear how many interviewers there were (1 or 2) and whether the 'research nurse' is one of them. Clarity is needed.

Lines 277 and 282 - the term 'participants' is used. 'Participants' refer to BOTH the HCPs and women. If the discussion is about how the women felt, then I would anticipate that 'participant' should actually be women. A similar issue arises throughout the theme "Impact of intervention on women's lives"

Other issues

Line 169 - what is meant by "reasoned, logical and valid"

Lines 179-180 : it is noted that "A review of field notes in conjunction with the transcripts addressed dependability". Dependability is normally addressed through the keeping of an audit trail. It is unclear how merely reviewing notes and transcripts addresses dependability. Explanation (with references) needed.

Line 274 - 'Verbal feedback' is referred to. Should this not be data from the interviews?

What is meant by 'fair proportion' -line 344

There is still some disconnect between the surrounding text and the quotes provided as evidence:

Eg

Lines 224 - 225. The main thrust of the quote is family relations but the text refers to lack of education

Lines 287 - 288. This quote is about 'confidence'. The link to how a person centred approach enables women to come forward is still unclear.

Lines 289 - 291 - the quote which refers to 'contained space' (I'm assuming is quite removed from where this was discussed in the text. Please consider inserting.

Lines 353 - 354 - Why is there a quote from a woman when the preceding text is related to HCPs?

Lines 429 - 434 - the preceding text refers to collaboration with stakeholders, supportive supervision and debriefing are discussed but different issues are raised in the quotes

Line 463 - how does 'adequate time' related to 'the best quality care' as described in the preceding text.

Written English. Although it is noted that the manuscript has been copy edited, there are a number of instances throughout where further work is required.

Eg:

Abstract:

Lines 36-37 : "Intervention participants expressed the counselling session as a safe haven....." Awkward expression

Line 64 - consider not using the term 'cases' to refer to women' (ie, the first time 'cases' is mentioned in the sentence)

Line 70 - The term 'programmes insufficient' is used. Are the programs insufficient or the number (or spread) of programs insufficient? See also line 83

Line 72 - what is meant by the 'enforcement' of the initiatives. Please consider using a more relevant term

Line 74 - Please reconsider the phrase 'larger segment of population in Nepal' - Awkward expression

Line 79 - I a review 'on' intervention, or 'about' interventions

Line 85 - What is meant by 'alert women against DFV' - Awkward expression.

Line 90 - we screen victims 'ford' DFV not 'of DFV'

Line 96 - change 'involvements' to 'involvement'

Line 151 - "....were read in conjunction with the transcribed verbatim". It appears word/s are missing.

Line 179 - What is meant by "a triangulation of researchers"?

Line 213 - Do you mean,.....'and overlapping in nature'?

Line 256 - change 'currently' to at the time the article was written, as this information may go out of date.

Line 259 - insert 'the' between 'notify' and 'hospital's'

Line 301-302 - ...learn how to respond to FV and some topics

Line 387 0 delete 'as well'

Line 515 - insert 'the' between 'of' and 'booklet'

Line 516- change 'after' to 'rather'

Line 518 - insert 'a' between 'DFV' and 'one-size-fits-all"

Line 520 - change 'influences' to 'influence'

Line 544- meaning of 'awareness on need of acting against DFV' is unclear

Line 545 - delete 'very'

Line 552 - this sentence reads as if the HCPs are disclosing the women's experiences. I'm sure this is not what was intended

Line 559 - delete 'the'

Line 564 - do you mean 'funding in this area'?

Line 573, delete the comma after 'Despite'

Line 581. Start a new sentence at 'this study'

Reviewer #4: This qualitative study examines the acceptability and utility of a psychosocial intervention, from the perspective of service users and health professionals. Overall, the authors have addressed the reviewers’ prior concerns and comments.

I’m not sure why the authors have chosen to use DFV for Domestic & Family Violence since the more common terms (and therefore more searchable by potential readers) are DV (domestic violence) or IPV (intimate partner violence). I recommend the authors use the most commonly used IPV.

While significantly improved over the initial submission, the manuscript requires copyediting for language usage, grammar and clarity. Related to this, some of the quotes were poorly translated into English.

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14 Feb 2020

A. Reviewer 2: Thank you for addressing issues raised in the previous review. Upon re-reviewing the manuscript, however, I would like to raise issues that I feel still require further response.

C1. There appears to be inconsistency in the stated aims of the research.

The abstract (lines 25-26) - "acceptability and the perceived impact of....[the intervention]

Finding - Line 382 - 'improvement and sustainability'. Although this is not an aim per se, it does highlight the inconsistency across the manuscript in what was being addressed through this particular study. Clarity and consistency needed.

The introduction (lines 135-119) - "....perceived strengths and limitations of [the intervention] (described as 'objectives'

R1: Thank you. We appreciate the reviewer’s comments.

To assess acceptability of any intervention, it is necessary to identify the perceived impact of that intervention (strengths) and barriers in implementing that intervention. In addition, exploring recommendations and suggestion from participants will help to design the intervention in the most effective way for future implementation. Hence, in the abstract section, general objective was stated and it was further broken down into specific objectives. (Page no. 7, line no. 115-119)

This study has two specific objectives.

• To explore the perceived strengths and limitations of the counselling and psychoeducation intervention as experienced by intervention participants and HCPs.

• To solicit feedback on what elements of the intervention and process could be improved and how.

The objective in the abstract was restructured to make it clearer and consistent. (Page no. 2, line no. 26-28)

As suggested, the sentence was restructured to ensure consistency. (Page no. 19, line no. 388-89)

C2. Line 133, reference is made to "the research nurse", yet line 139 refers to "Both interviewers'. It is unclear how many interviewers there were (1 or 2) and whether the 'research nurse' is one of them. Clarity is needed.

R2: Thank you for the information.

The research nurse (RP) had interviewed participants from the intervention group and the intervention nurse (DS) had interviewed HCPs.

This had been mentioned in the Data Collection section and to make it clearer, initials of both interviewers have been added in the text.

(Page no. 8, line no. 134, 137, 141)

C3. Lines 277 and 282 - the term 'participants' is used. 'Participants' refer to BOTH the HCPs and women. If the discussion is about how the women felt, then I would anticipate that 'participant' should actually be women. A similar issue arises throughout the theme "Impact of intervention on women's lives"

R3: Thank you for your feedback.

This study had explored perspectives of both the service providers and service users. It is not just about how women felt but also how service providers felt about the intervention. Hence, ‘participants’ term was used to indicate both of them and either woman or HCP was used after each quote to make the reader better understand which quote was said by whom.

C4. Line 169 - what is meant by "reasoned, logical and valid"

R4: Thank you for pointing this out.

The interpretation made in the result section was rigorously discussed among the research team to ensure it is logical and valid. Furthermore, appropriate reasoning was put forward to support the findings presented.

As suggested the sentence was restructured to make it clearer. (Page no. 9; line no. 171)

C5. Lines 179-180 : it is noted that "A review of field notes in conjunction with the transcripts addressed dependability". Dependability is normally addressed through the keeping of an audit trail. It is unclear how merely reviewing notes and transcripts addresses dependability. Explanation (with references) needed.

R5: Thank you for pointing this out.

This section has been amended. (Page no. 10; line no. 182-84)

C6. Line 274 - 'Verbal feedback' is referred to. Should this not be data from the interviews?

What is meant by 'fair proportion' -line 344

R6: Thank you for your feedback. This has been revised as suggested. (Page no. 14; line no. 279). The proportion is now quantified to make it clearer. (Page no. 17; line no. 348)

C7. There is still some disconnect between the surrounding text and the quotes provided as evidence:

Eg

Lines 224 - 225. The main thrust of the quote is family relations but the text refers to lack of education

R7: Thank you for your feedback. In this section, some contributing factors of DFV as expressed by participants were presented. The sentence was restructured to make it clearer. (Page no. 12; line no. 226-227)

Other quotes were also reviewed and arranged appropriately to ensure that the surrounding text align with the quotes provided.

C8. Lines 287 - 288. This quote is about 'confidence'. The link to how a person centred approach enables women to come forward is still unclear.

R8: Thank you for your feedback.

Person-centered approach would encourage women to express themselves without hesitation and address their individual needs and concerns. This approach would improve confidence among women to share their problem with HCPs.

C9. Lines 289 - 291 - the quote which refers to 'contained space' (I'm assuming is quite removed from where this was discussed in the text. Please consider inserting.

R9: Thank you for your feedback. There is a quote referring to contained space in Page no. 15; line no. 294-296.

C10. Lines 353 - 354 - Why is there a quote from a woman when the preceding text is related to HCPs?

R10: Thank you for your feedback. Explanatory text was added before the quote to make it clearer. (Page no. 18; line no. 358-59)

C11. Lines 429 - 434 - the preceding text refers to collaboration with stakeholders, supportive supervision and debriefing are discussed but different issues are raised in the quotes

R11: Thank you for your feedback.

‘All higher authorities need to be involved’ (Page no. 21; line no. 440) – This implies collaboration with the stakeholders at all level for proper implementation of the program.

C12. Line 463 - how does 'adequate time' related to 'the best quality care' as described in the preceding text

R12: When there will be a decrease in patient load, health care providers will get adequate time for discussing with patients, which is crucial for improving the effective doctor-patient relationship. This approach would ensure correct identification and management of the patient’s issue. However, failure to allocate adequate time for patient’s consultation might raise several issues such as misdiagnosis, miscommunication and lack of empathy from the doctor leading to distrust from the patients.

(Ref: https://praxhub.com/are-your-patients-receiving-adequate-time-and-quality-care/)

C13. Written English. Although it is noted that the manuscript has been copy edited, there are a number of instances throughout where further work is required.

Eg:

Abstract:

Lines 36-37 : "Intervention participants expressed the counselling session as a safe haven....." Awkward expression

Thank you for your feedback.

The sentence has been restructured to make it clearer. (Page no. 2; line no. 37-38)

Line 64 - consider not using the term 'cases' to refer to women' (ie, the first time 'cases' is mentioned in the sentence)

Thank you for your feedback. The suggested change has been made. (Page no. 4; line no. 62)

Line 70 - The term 'programmes insufficient' is used. Are the programs insufficient or the number (or spread) of programs insufficient? See also line 83

Thank you for your feedback. The sentence has been restructured to make it clearer. (Page no. 4; line no. 70-72; Page no. 5; line no 83-84)

Line 72 - what is meant by the 'enforcement' of the initiatives. Please consider using a more relevant term

Thank you for your feedback. The sentence has been restructured to make it clearer. (Page no. 4; line no. 72-73)

Line 74 - Please reconsider the phrase 'larger segment of population in Nepal' - Awkward expression

Thank you for your feedback.

The sentence has been restructured to make it clearer. (Page no. 5; line no. 74-75)

Line 79 - I a review 'on' intervention, or 'about' interventions

Thank you. Change has been made as suggested. (Page no. 5; line no. 79)

Line 85 - What is meant by 'alert women against DFV' - Awkward expression.

Thank you for your feedback. The sentence has been restructured to make it clearer. (Page no. 5; line no. 85)

Line 90 - we screen victims 'ford' DFV not 'of DFV'

Thank you. Change has been made as suggested. (Page no. 5; line no. 90)

Line 96 - change 'involvements' to 'involvement'

Thank you. Change has been made as suggested. (Page no. 5; line no. 96)

Line 151 - "....were read in conjunction with the transcribed verbatim". It appears word/s are missing.

Thank you for your feedback. The sentence has been restructured to make it clearer. (Page no. 8-9; line no. 152-54)

Line 179 - What is meant by "a triangulation of researchers"?

Triangulation of researchers means involvement of multiple researchers/observers with different areas of expertise. This approach enables securing as many different views as possible during the analysis of the qualitative data (Denzin, 1978). Available in https://qualpage.com/2018/01/18/triangulation-in-qualitative-research/

Line 213 - Do you mean,.....'and overlapping in nature'?

Thank you. It has now been corrected. (Page no. 11; line no. 217)

Line 256 - change 'currently' to at the time the article was written, as this information may go out of date.

Thank you. It has now been corrected. (Page no. 13; line no. 258-59)

Line 259 - insert 'the' between 'notify' and 'hospital's'

Thank you. Change has been made as suggested. (Page no. 13; line no. 263)

Line 301-302 - ...learn how to respond to FV and some topics

Thank you. We appreciate the reviewer’s comments. We have rechecked the line highlighted to ensure it is correct.

Line 387 0 delete 'as well'

Thank you. As suggested, ‘as well’ was deleted. (Page no. 19; line no. 394)

Line 515 - insert 'the' between 'of' and 'booklet'

Thank you. As suggested, ‘the’ was added. (Page no. 25; line no. 522)

Line 516- change 'after' to 'rather'

Thank you. Change has been made as suggested. (Page no. 25; line no. 524)

Line 518 - insert 'a' between 'DFV' and 'one-size-fits-all"

Thank you. Change has been made as suggested. (Page no. 25; line no. 526)

Line 520 - change 'influences' to 'influence'

Thank you. Change has been made as suggested. (Page no. 25; line no. 528)

Line 544- meaning of 'awareness on need of acting against DFV' is unclear

Thank you for your feedback. The sentence has been restructured to make it clearer. (Page no. 26; line no. 552-54)

Line 545 - delete 'very'

Thank you. The necessary amendment was made. (Page no. 26; line no. 553)

Line 552 - this sentence reads as if the HCPs are disclosing the women's experiences. I'm sure this is not what was intended Thank you. The sentence has now been restructured to make it clearer. (Page no. 27; line no. 559-62)

Line 559 - delete 'the'

Thank you. The necessary amendment was made. (Page no. 27; line no. 568)

Line 564 - do you mean 'funding in this area'?

Thank you. The necessary amendment was made. (Page no. 27; line no. 573)

Line 573, delete the comma after 'Despite'

Thank you. As suggested, a comma was added. (Page no. 28; line no. 582)

Line 581. Start a new sentence at 'this study'

Thank you for your feedback (Page no. 28; line no. 594)

B. Reviewer’s 4 comments

This qualitative study examines the acceptability and utility of a psychosocial intervention, from the perspective of service users and health professionals. Overall, the authors have addressed the reviewers’ prior concerns and comments.

C1. I’m not sure why the authors have chosen to use DFV for Domestic & Family Violence since the more common terms (and therefore more searchable by potential readers) are DV (domestic violence) or IPV (intimate partner violence). I recommend the authors use the most commonly used IPV.

R1: Thank you. We appreciate the reviewer’s suggestion. We do agree that IPV is the most common term, however, all of the authors have had discussions about the best terminology to be used in the article at the time of the protocol development. Agreement on using DFV was based on the understanding that in the setting where the study was conducted, (i.e. Nepal, the perpetrators include not only the husband, but other family members, including father, mother, and brother-in-laws. This has been described in the protocol paper which has been published elsewhere. The link to the protocol paper is

https://bmjopen.bmj.com/content/9/4/e027436

C2. While significantly improved over the initial submission, the manuscript requires copyediting for language usage, grammar and clarity. Related to this, some of the quotes were poorly translated into English.

R2: The manuscript has been thoroughly reviewed and grammatical errors have been rectified. Two of the authors are native English speakers who have reviewed again for English edits.

Submitted filename: Responses_reviewers_R2_14022020.docx

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21 Feb 2020

‘We don’t see because we don’t ask’: qualitative exploration of service users’ and health professionals’ views regarding a psychosocial intervention targeting pregnant women experiencing domestic and family violence

PONE-D-19-22252R2

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26 Feb 2020

PONE-D-19-22252R2

‘We don’t see because we don’t ask’: qualitative exploration of service users’ and health professionals’ views regarding a psychosocial intervention targeting pregnant women experiencing domestic and family violence

Dear Dr. Sapkota:

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