RESEARCH ARTICLES

Confronting domestic violence within the family health strategy

Nadirlene Pereira Gomes^I; Aiara Nascimento Amaral Bonfim^II; Rafael Damasceno Barros^III; Cláudio Claudino da Silva Filho^IV; Normélia Maria Freire Diniz^V

ABSTRACT: A descriptive and qualitative study aiming to identify factors that contribute to confronting domestic violence. In 2011, interviews were conducted with 14 professionals working in family health units in Bahia, Brazil. All ethical aspects were considered. The study showed that the identification of conjugal violence and injury associated with women necessities in the health service, the notification of suspected or confirmed cases, the perception by professionals of the phenomenon complexity and inter-sector coordination with other areas of attention are elements that contribute to confront the problem. These elements can direct public health efforts to raise awareness, train and engage professionals to face issues that threaten public health, such as domestic violence.

Keywords: Public health; violence against women; inter-sector action; family health program.

INDRODUCTION

More than 38,000 Brazilian women are assaulted daily. Of these, 68.8% suffer violence from their own spouses¹, characterizing conjugal violence. In general, violence against women is responsible for decreased productivity at work, representing an economic burden to society. In Brazil, it is estimated that the cost of domestic violence is 10.5% of gross domestic product (GDP)².

It is worth noting that such experiences increase the chances of developing diseases and affects women’s health³. Taking into account that the high demand of women for health services, particularly within the family health strategy (FHS), makes health professionals potential recognizers of violence experienced by women, the health sector plays a leading role in the process of confronting domestic violence.

Given the importance of health professionals and considering the need for studies and research on the subject, as recommended by the ‘Maria da Penha’ Law4, this study aimed to identify factors that contribute to confronting domestic violence from the perspective of the FHS professionals.

LITERATURE REVIEW

Violence against women is considered a form of violation of human rights, rooted in gender inequality, responsible for socially shared vision of the power of men over women. This asymmetrical power relationship gives rise to the construction of marital violence.

Violence has been a major cause of morbidity and mortality worldwide, affecting the physical and mental health of women, who tend to present signs and symptoms, such as bruising, fractures, burns, abdominal and muscle pains, headaches, sexually transmitted diseases, unwanted pregnancies, abortions, premature deliveries, adjustment difficulties, social isolation, insomnia, anxiety, palpitations, nervousness, insecurity, low self-esteem, depression, alcohol and other drug use, post-traumatic stress disorder, suicide attempts and death⁴.

Faced with the need to make the problem visible, it is necessary that health professionals are aware of the fact that violence traumatizes, disables, humiliates, frustrates, alters behaviour and has consequences, and that they view it as a health issue and therefore, as part of their work^5,6. Thus, violence constitutes a relevant problem for those in technical roles, scholars and/or health care workers.

The FHS, for its coverage and linking with the community, promotes recognition of the disorder by professionals⁵, revealing itself as an important tool to combat this phenomenon, which requires articulation and therefore cannot be limited to linear and isolated actions.

METHODOLOGY

This is a descriptive and exploratory study with a qualitative approach, conducted with professionals working in FHS teams in the State of Bahia, Brazil.

The study population consisted of social workers (SW), dentists (D), nurses (N), physicians (P), community health agents (CHA), nurse aids and nursing technicians (NT) who had been practicing in the FHS for at least six months. They have been identified in their testimonials with the initial letters by professional category and number of study entry. Although the smallest teams in the FHS do not include the presence of the social worker, it is worth noting that the municipality in question, recognizing the importance of this work with public policy users, maintains a social worker in all its teams through its own resources.

After approval by the Research Ethics Committee (No. 01/2011), employees were informed about the purpose and relevance of the research and the following ethical aspects: free will to participate (or not) in the study; the right to withdraw at any time; confidentiality of information; and the risk offered by the survey, which is low. Upon accepting to participate, professionals were invited to sign the Terms of Free and Clear Consent, which contained the record of the aforementioned ethical issues, which are based on Resolution No. 466/2012.

As a data collection tool, we used the semi-structured interview with guiding questions related to professional conduct on women in situations of domestic violence.

The interviews were conducted individually and in a reserved place, with an average duration of 35 minutes in the physical space of the family health units (FHU) where each professional works, from January to May 2011. 14 workers from eight FHSs were interviewed: two doctors, two nurses, two dentists, four social workers, three CHAs and a nursing technician. Their answers were recorded by digital recorder, converted in a specific program, stored on DVS and transcribed through Microsoft Office Word.

The data was organized and coded according to the content analysis, in the thematic analysis modality. This method aims to achieve, through systematic and objective procedures of description, the content of messages and reach the core meanings of the collected material. The operational method consists of three steps: pre-analysis, material exploration and processing of the results by inference and interpretation⁷. After a thorough reading of the raw material, the so-called pre-analysis, the analysis itself began, with the exploration of the material and the subsequent coding of data, with the choice of reporting units. Such a systematic process of transformation of raw data allowed the definition of the following thematic categories: Identification of domestic violence within public health; Notification of domestic violence; Perception of domestic violence; and Inter-sector articulation.

RESULTS AND DISCUSSION

The study unveiled elements that contribute to facing the problem, presented from the categories discussed below.

Identification of domestic violence by public health

The recognition of the experience of domestic violence by the woman who turns to the health care service is still a challenge for some professionals who work in the FHS of the researched municipality. The statements below allow illustration of this situation:

[...] Honestly, in two years of Family Health, I have not had any case of domestic violence. (SW5)

I’ve never been through a situation of attending a woman suffering violence. (N7)

I’ve been in primary care for nine years already and a case of domestic violence never came [...] not that I’ve never noticed. (D7)

Although studies have indicated FHS as strategic for the identification of domestic violence against women, especially by continued service and the bond between users and institutions, which is favoured by FHS, the responses point to the difficulty of such recognition by professionals. Research in the same municipality had already pointed to the difficulty of identifying domestic violence by health professionals and their association with physical injury, signalling us to the invisibility of violence in health services⁸. This difficulty is related to the absence of academic preparation for students in the health areas regarding the different dimensions of the human being, including the issues that generate gender violence in the day-to-day practice of health services, coupled with a lack of professional training⁹.

Given the above, there is the need for opportunities to introduce this theme into academic and professional raining to enable professionals to identify the grievance and enhance understanding of the complexity of the phenomenon. It is worth pointing out that upon recognizing the grievance, it is important for professionals to record the identified or suspected history in the patient’s chart, as well as the guidance given, because these are documents that can be incorporated into the files of the police investigation¹⁰.

It is important to note the relationship of trust and listening in the identification of the grievance process¹¹, since the identification of problems should go beyond the biological, using subjectivity through an empathic relationship, which relates to the professional interest of knowing the families’ and community’s functionality, in line with the assumptions espoused by the National Humanization Policy (NHP)¹ and the proposed FHS expanded care¹². The ability to listen to users and recognize them as the subjects of the health and illness process are prerequisites for promoting the inclusion defended by NHP1. From this perspective, the identification of the violent experiences is related to the way inclusion occurs during health care.

Notification of domestic violence

It can be seen that completing the Personal investigation of domestic, sexual and/or other interpersonal violence Notification file is not a daily practice in the health service:

I haven’t heard of the violence against women notification form. (CHA1)

[...] I know I have to notify, but do not know how it works. I’m not even trained to talk about it. (N6)

The professionals’ comments suggest underreporting of violence in the municipality and lack of knowledge about the form, as well as the notification process.

Although the reporting of violence has not yet been implemented in the city, since 2003 Law No. 10,778 states that all health care services – public or private – must report suspected or confirmed cases of violence, considering the non-compliance of notification as a violation of legislation regarding public health¹⁰. However, many professionals violate what the law requires, which couples the lack of regulatory and punitive norms with professional unpreparedness for the identification of violence in services and the lack of knowing that notification is confidential, thus the fear of reprisals¹³. Misunderstanding that notification is a report, as well as the other situations mentioned, constitute obstacles to taking action¹⁴.

From this perspective, a management within the FHS which seeks to employ notification as a routine in its services becomes essential, making use of strategies of professional qualification in services that address the relevance of notification, its course and completion process.

Perception of domestic violence

Noteworthy is the perception of domestic violence as a police problem, in view of the fact that several interviewees restrict their professional conduct to referral to the women’s police station:

My advice is that she seeks out the women’s police station. (CHA1)

[...] there is a specialized police station catering to women. Referrals are basically to the precinct. (N6)

I talked to her and made it clear that we have a specialized police here. (SW6)

The perception that the complaint is the only instrument of resolution to the situation of violence is a paradigm that does not reflect this socio-historical-cultural phenomenon, as it has repercussions in several areas of knowledge: social, economic, political, legal and biological⁸.

The non-perception of marital violence as health issue ultimately makes women even more vulnerable to illness by living an everyday life permeated by disrespectful actions. Feeling unattended to by health professionals and resolved not to file complaints, women remain silent. Below are illustrative comments:

There is a difficulty for them to get the courage to file a report, because their husbands will go to jail and then they will not have income [...]. (P4)

I referred her to the police station, but she told me she wouldn’t go because of the children and also because she wouldn’t have anywhere to go. (SW6)

They fail to report out of shame, so the community doesn’t know that they suffer this problem. (NT2)

Professionals share the perception that shame, children and women’s economic dependence contribute to the decision not to report, suggesting the complexity of the phenomenon. However, beyond the embarrassment of public disclosure and financial dependence, the desire to keep the family together, emotional dependency and fear of reprisals coexist, plus the feeling of impunity regarding the complaint¹⁵. Women remaining in marital relationships can also be understood from a gender perspective, since the unequal relationships built and shared socially sustain the idea of male superiority over women, on which were based popular sayings such as “don’t get involved in a couple’s argument”¹⁶.

Regardless of the reasons for women’s silence, professionals must be prepared to investigate the violence¹¹, as imperceptions of the complexity of the grievance require strategies to educate professionals on the theme. Such preparation requires an academic education and service that addresses domestic violence as a health issue¹⁷.

There is a need to review the pedagogical proposals of educational and service institutions, looking for educational processes that include discussions on violence against women from a gender perspective. It is believed that a broader perception about the phenomenon will oblige professionals working in the areas of health to meet the demands of women with a history of domestic violence.

Inter-sector coordination

Articulation between the health sector with other services is seen by professionals as an indispensable strategy for confronting domestic violence:

Articulation is missing by everyone in team working. [...] in making referrals. (N6)

[...] There is no network. A lack of refuges. The Specialized Women’s Precinct (SWP) has now been created. (SW3)

These comments by professionals demonstrate an understanding that the health service, by itself, cannot cope with the demands of women in situations of domestic violence, reaffirming the importance of the interconnections for communication and the flow of referrals between the different services that make up the network to assist women in situations of violence. This finding confirms that addressing violence cannot be confined to isolated actions, guided by linearity, but requires working in networks¹⁸.

Worth highlighting is the fact that in the municipality there is no SWP as mentioned in the professionals’ responses, but a Core Precinct Specializing in Women’s Attention (CPSWA), linked to the Department of Social Development (DSD), operating since 8 March 2011, with the provision of legal services and social and psychological support to women in situations of violence. The Reference Centre for Women’s Health (RCWH), also cited by the professionals, was created in 2009 with the objective of attending women living in areas without FHS coverage, providing care in cardiology and gynecology with high-risk pre-natal services. Although being an important service for women, it is not targeted for women in situations of violence.

However, many professionals do not even know about the services to women in situations of violence:

I do not see any kind of service for specific care here in the city. (P5)

There is the women’s police station that opened here a little while ago. (N6)

[...] there’s the RCWH which is the women’s clinic and the SWP. Around here, I think only these. (CHA2)

Ignorance regarding the services was also mentioned in a research aiming to examine the importance of interdisciplinary and inter-sector approaches to fighting domestic violence against women. The study also added the limited institutional capacity to make decisions and fragmented and isolated actions. Services should seek strategies for inter-sector coordination for networking¹⁸.

Since 2006, with the enactment of ‘Maria da Penha’ Law, the creation of joint actions with the support of the Union, the States, the Federal District, municipalities, non-governmental spaces; integration between the judiciary, the prosecution and the Public Defender’s Office and the areas of public safety, welfare, health, education, employment and housing has been advocated⁴.

Inter-sector coordination, recognized by professionals as an essential strategy to combat violence, seeks to ensure the involvement of various sectors of society. It is important to the development of professional skills for such actions in order to encourage referrals of women, considering their demands. It is believed that this form does not restrict referrals to police stations, in fact increasing the chances of promoting the care of women in situations of violence.

Worth noting is that when forming a network, professionals need to have working conditions that enable them to participate in common spaces of communication with representatives of other services¹⁸.

CONCLUSION

Professionals working in the FHS understand that the identification of domestic violence in health care, notification of the grievance, the perception of their complexity and inter-sector collaboration are elements that contribute to combating this phenomenon.

The portrait of a Northeast Brazilian country side reality shows that the identification of conjugal violence is incipient by the health professionals surveyed. This is related to the lack of understanding of domestic violence as demand for women’s health and the little insight as to the complexity of the phenomenon. Faced with such a professional unpreparedness, underreporting and deficiencies in articulation by the service network are a reality.

The study reaffirms the importance of inter-sector coordination, to ensure that women are included in their various demands. The construction or redesign of a Guide for Care Services to Persons in Situations of Violence for the municipality is recommended, listing the health, social, judicial, police and other existing services in the region, considering the social network support, which may facilitate the communication between the services and referrals network. This process requires commitment and policy planning at the local level, from a management that enhances inter-sector coordination.

A transformation of academic and in-service training model to raise awareness is crucial, in order to qualify and engage professionals to face issues involving public health, such as domestic violence. Changes in pedagogical proposals are vital to understanding the magnitude and complexity of violence, empowering professionals to identify hazards, notifications and referrals.

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