Revealing outcomes of care for women in situations of domestic violence

Abstract

Objective

To reveal healthcare professionals’ perceptions about the outcomes of care for women in situations of marital violence.

Methods

This is a qualitative approach study based on the Grounded Theory theoretical-methodological framework. For data collection, interviews were carried out with two sample groups composed, in total, of 31 higher education healthcare professionals, members of the minimum team or of Family Health Support Nucleus of Family Health Units in a health district in a capital of northeastern Brazil.

Results

From the participants’ narratives, outcomes of care for women in situations of marital violence were elucidated, which are organized into two representative categories: Providing marital violence tackling from women empowerment and Compromising marital violence tackling due to non-care, the latter being composed of two subcategories entitled Vulnerating women to remain in an abusive relationship and Making women susceptible to illness/death.

Conclusion

The offer of qualified assistance in services directly impacts the lives of women who experience violence, whether positively or negatively, since non-care can reverberate in women’s health and even result in their death. Providing a welcoming assistance, professionals favor female empowerment, thus contributing to the tackling conjugal violence.

Violence against women; Intimate partner violence; Women’s health; Adaptation, psychological; Primary health care

Resumo

Objetivo

Revelar as percepções dos profissionais de saúde sobre os desfechos do cuidado com a mulher em situação de violência conjugal.

Métodos

Estudo de abordagem qualitativa embasado no referencial teórico-metodológico da Teoria Fundamentada nos Dados. Para a coleta de dados, foram realizadas entrevistas com dois grupos amostrais compostos, no total, de 31 profissionais de saúde de nível superior integrantes da equipe mínima ou do Núcleo de Apoio à Saúde da Família de Unidades de Saúde da Família de um distrito sanitário localizado em uma capital do Nordeste brasileiro.

Resultados

A partir das narrativas das participantes da pesquisa, foram elucidados desfechos do cuidado com a mulher em situação de violência conjugal, os quais estão organizados em duas categorias representativas: Propiciando o enfrentamento da violência conjugal a partir do fortalecimento da mulher e Comprometendo o enfrentamento da violência conjugal em razão do não cuidado, sendo essa última composta por duas subcategorias intituladas Vulnerabilizando a mulher para permanência na relação abusiva e Suscetibilizando a mulher para o adoecimento/morte.

Conclusão

A oferta de uma assistência qualificada nos serviços impacta diretamente na vida das mulheres que vivenciam violência, seja positiva ou negativamente, uma vez que o não cuidado pode reverberar em agravamentos à saúde da mulher e resultar, inclusive, em seu óbito, enquanto que, ao prestar uma assistência acolhedora, o profissional favorece o empoderamento feminino e, assim, contribui para o enfrentamento da violência conjugal.

Violência contra a mulher; Violência por parceiro íntimo; Saúde da mulher; Adaptação psicológica; Atenção primária à saúde

Resumen

Objetivo

Revelar las percepciones de los profesionales de la salud sobre los resultados del cuidado de mujeres en situación de violencia conyugal.

Métodos

Estudio de enfoque cualitativo basado en el marco referencial teórico-metodológico de la teoría fundamentada en los datos. Para la recopilación de datos se realizaron encuestas con dos grupos de muestras compuestos, en total, por 31 profesionales de la salud de nivel superior integrantes del equipo mínimo o del Núcleo de Apoyo a la Salud de la Familia de Unidades de Salud de la Familia de un distrito sanitario ubicado en una capital de la región Nordeste brasileña.

Resultados

A partir de las narrativas de las participantes del estudio, fueron ilustrados los resultados del cuidado de mujeres en situación de violencia conyugal, y se organizaron en dos categorías representativas: Propiciar el afrontamiento a la violencia conyugal a partir del fortalecimiento de la mujer y Comprometer el afrontamiento a la violencia conyugal por causa del no cuidado, y esta última se dividió en dos subcategorías tituladas: Vulnerar a la mujer para que permanezca en la relación abusiva y Susceptibilidad de la mujer para que se enferme/muera.

Conclusión

Ofrecer una asistencia calificada en los servicios impacta directamente en la vida de las mujeres que sufren violencia, ya sea de forma positiva o negativa, dado que el no cuidado puede repercutir en el agravamiento de la salud de la mujer y puede, inclusive, provocar su muerte; mientras que, al proporcionar una atención acogedora, el profesional favorece el empoderamiento femenino y, de esta forma, contribuye con el afrontamiento a la violencia conyugal.

Violencia contra la mujer; Violencia de pareja; Salud de la mujer; Adaptación psicológica; Atención primaria de salud

Introduction

Domestic violence is a persistent public health problem linked to the hegemonic macho culture. Given the magnitude and complexity of this problem, efforts have been made, at the international and national levels, to promote care strategies for women in the social and institutional sphere, so that they can find mechanisms to face the problem.

Worldwide, it is estimated that one in three women experience domestic violence.(¹) This phenomenon represents a public health problem that has been present in women’s daily life since antiquity, being anchored in male supremacy. The 1890 penal code itself allowed for the acquittal of murder crimes committed against women considered to be passionate, under the justification of legitimate defense in the name of male honor.(²) This prerogative remains, even being used in contemporaneity as an attempt to reverse the penalty in cases of human treachery.(³)

As it is a global phenomenon, confronting it, through the promotion of gender equality and female autonomy, was considered one of the priority goals of the millennium, which is a commitment signed by the governments of 191 member countries of the Organization of United Nations (UN), including Brazil.(⁴) This country also occupies a prominent position on the international scene with regard to fighting violence against women, since it was through the Convention of Belém do Pará that it was established in the South American continent. right of women to live a life free from violence, considering this a violation of human rights.(⁵) It was precisely anchored in this convention that the Maria da Penha Law was enacted in 2006, which creates mechanisms to curb domestic and family violence against women in the country. According to the UN, this is one of the most effective laws in the world to combat domestic and family violence, second only to countries like Spain and Chile.(⁶)

It is important to point out that women’s exit from the situation of violence is not limited to legal-police support, being essential the presence of an institutional and social support network, consisting of other services, such as health and social action, in addition to the family, friends, neighbors and the church, in a complementarity between informal and formal social support, supported by professional agents and specialized agencies. This type of support has been carried out in a peculiar way in the current context of social distancing resulting from the pandemic caused by the new coronavirus in the country, as it encourages women to use codes, such as an “X” mark on the palm of the hand, which signal the condition of violence when contacting friends and family, as well as neighbors, and that they pay attention to possible cases of domestic aggression and other forms of violence, such as isolation and restriction of contacts, in addition to reasonable and linked to protection from contagion.(⁷) Through this support, a woman can feel strengthened and encouraged to break off the abusive relationship. It is noteworthy, however, that this decision-making process is unique, involving different time and thresholds for each person – hence the relevance of a permanent and persistent multidisciplinary care.(⁸)

Specifically about health care, professionals working in Primary Care, as they are closer to the population and at the main gateway to health services, play a fundamental role, both in identifying situations of violence and in conducting cases, providing guidance on services available on the network that can help victims(⁸)and also to raise awareness of other people, such as neighbors, of the importance of getting involved in mutual protection. The relevance of preventive actions and the promotion of a culture of peace is also highlighted, which can help women to analyze the possible paths for the peaceful resolution of conflicts and confrontation of violence.(⁶)

From this perspective, it is believed that, while adequate care practices can help women to get out of the situation of violence and alleviate the damage resulting from this injury, omission, in turn, can negatively impact the confrontation of this problem. Thus, the question is: What are the healthcare professionals’ perceptions about the outcomes of care for women in situations of domestic violence?

In order to answer this question, the objective of this study is to reveal healthcare professionals’ perceptions about the outcomes of care for women in situations of domestic violence.

Methods

In this study, a qualitative approach was adopted based on the methodological framework of Grounded Theory. Such method comprises a given reality through the meanings attributed to it, so that, from a systematic analysis of the data found, it becomes possible to create a theory.(⁹)

The study is linked to a matrix project entitled “Enfrentamento da violência conjugal no âmbito do Sistema Único de Saúde: tecnologia social envolvendo mulheres, homens e profissionais da atenção básica”, which was included in the public notice Program Research for SUS: Shared Management in Health and received financial support from the Bahia State Research Support Foundation with the Department of Health of the State of Bahia and the Ministry of Health.

The locus chosen for the study were 22 Family Health Units in the health district of a Brazilian capital with high rates of violence and social vulnerability. In them, 31 higher education professionals were intentionally chosen, 26 from Family Health Units and five from Family Health Support Nuclei, representing, respectively, the first and second sample group. Professionals working a minimum of 6 months at Family Health Unit were included. Professionals absent due to health reasons or absence from interviews three times without justification were excluded.

The interviews, which took place between February and December 2019 and lasted an average of 50 minutes, were guided by a semi-structured form containing objective questions, aimed at characterizing the participants, and subjective ones, guided by the proposition: “Tell me about the impacts related to the care offered to women in situations of domestic violence”. Simultaneously, data transcription, organization and analysis took place with the help of NVivo 10 software, from which the following hypothesis emerged: “Professionals from the reference Family Health Strategy team share the understanding that psychologists and social workers are better prepared to provide care for women in situations of marital violence”, which guided the second sample.

As proposed by Grounded Theory, the data obtained were submitted to open, axial and selective coding processes. Then, analytical categories were elaborated and the study phenomenon was formulated, resulting from the integration of the paradigmatic model’s three elements (conditions, actions-interactions and consequences/outcomes), which was named “Enabling women empowerment in situations of marital violence”. It should be noted that this study aims related to the consequences of this phenomenon, which emerged from the reports of participants about care provided to women in situations of domestic violence within the scope of Family Health Strategy.

The research is approved by an Institutional Review Board and meets the recommendations in Resolution 466/2012 of the Brazilian National Health Council (Conselho Nacional de Saúde), having been approved through Opinion 2.639224. To this end, participants’ privacy and anonymity were ensured, while interviews were conducted individually, and the speeches were presented in codes, such as “I1G1”, where the first number represents the interview order (I) and the second, the sample group (G). The data, as well as the Informed Consent Form signed by participants, must remain archived for 5 years; after this period, they may be deleted/destroyed.

Results

The study had the collaboration of 31 professionals who worked, on average, for 9 years, in the Family Health Unit of a health district located in a capital of northeastern Brazil. Of these, 29 were female and two were male, 17 nurses, five doctors, four dentists, three psychologists and two social workers. The average age was 38.5 years, and 80% had completed a lato sensu graduate course with thematic coverage in Family Health or Public Health. The narratives referred to two representative categories, respectively, of care offered or not offered to women in Family Health Strategy.

Providing marital violence tackling from women empowerment

As evidenced in the professionals’ statements, care for women in situations of domestic violence favored women empowerment. In this regard, professionals prepared to provide care provided women empowerment, who felt supported and safe to break the abusive relationship.

When I mentor a woman in this situation, I realize that she feels she is not alone, that she will be supported and strengthened. This helps her to face violence. (I18 G1)

I’m mapping with her the possibilities so as not to suffer more violence. I try to rescue family support. I think it helps a woman to get stronger. She chooses paths until she feels safe to break through [...]. You know we are always here to support her. (I5 G2)

Compromising marital violence tackling due to non-care

Failure to take care of women in situations of marital violence compromised women’s empowerment to face the problem. The lack of an organized management to identify and act on the problem resulted in damage, expressed in the following subcategories.

Vulnerating women to remain in an abusive relationship

The statements reveal that the lack of care, linked to the feeling of impotence or unpreparedness to deal with the problem, hindered women’s exit from the relationship of conjugal violence. By compromising the implementation of coping actions, this context ended up making the female population more susceptible to remain in the abusive relationship.

I was not trained, [...] I feel powerless to deal with these cases. I know this contributes to their remaining vulnerable to a new situation of violence. (I3 G1)

Some colleagues do not approach, even when they are suspicious. That’s keeping the person in trouble. (I2 G2)

Making women susceptible to illness/death

Professionals recognized that not taking care of women who experienced violence resulted in exposure to recurrent aggressions from their partners. Thus, abstaining from care could be an important factor for unfavorable outcomes, making them susceptible to mental illness, which could even lead to suicide.

Some professionals do not address violence because they believe it is not their responsibility. This harms the woman who remains exposed to all kinds of aggression. [...] continues to be afraid, ashamed, depressed, and may even commit suicide. (I20 G1)

A woman who suffers violence and is not cared for becomes even more sick, which can lead to the victim’s death. (I4 G2)

Discussion

The study is limited by not having assessed whether the care given to women has been a praxis guided by management, a situation that may have influenced the different outcomes presented. Despite this, the investigation highlights the importance of caring for women in situations of conjugal violence and offers elements to guide a management in the context of Family Health Strategy for preventing and tackling violence against women, highlighting the importance training and qualification dedicated to supporting women in situations of violence in their conjugal relationship.

The professionals’ narratives reveal that the conduct of care offered to women in situations of marital violence in the context of Primary Health Care can favor or hinder coping with the problem. Regarding continuity of women in a violent relationship, a consequence of limited and non-holistic care, the study indicates that this outcome is related to the lack of contact of professionals with the subject during their training, whether in the academic context or in training throughout their career. A study carried out in northeastern Brazil reveals that this lack of familiarity with the subject makes professionals even stop questioning women about the experience of violence, even in the face of suspicion,(¹⁰) what, for the study, is analogous to holding women hostage to the situation.

In this study, we evidenced that the lack of knowledge on the subject makes professionals lose the opportunity to help women in coping with the problem, contributing to the maintenance of a violent relationship. To overcome this limitation, it is essential that training to act in cases of conjugal violence is carried out since graduation, through the inclusion of the theme in the teaching plans, and continues throughout professional life, through continuing education.(¹¹) In this regard, the British government, in 2016, recognized that the lack of continuous training for professionals who work in situations of domestic violence can contribute to failures in identifying the problem.(¹²) On the other hand, an investigation carried out in the United Kingdom with 64 healthcare professionals showed that the training enables workers to address the issue of violence in all contacts with users, even favoring the event recognition, even in the absence of visible signs.(¹³) This situation, as revealed in a study carried out with 33 Nigerian victims of conjugal violence,(¹⁴) corroborates the importance of professional training to recognize the experience of abuse - an essential condition for the direction of attention with the purpose of dealing with the problem.

This careful way of providing assistance, based on knowledge and permeated by technical-scientific training, offers security to deal with situations of violence. The comprehensiveness of the complexity that involves the phenomenon can contribute to professionals adopting an attitude of respect towards women’s time to break the cycle of violence and not feel frustrated with the slowness of the outcome and the victim’s choices - which is not always meet what is expected by professionals.(⁸,¹⁵) Provision of care is, in this way, centered on the woman and on her expectations, needs and anxieties, without overlapping with her. Thus, considering the interactional processes that define or not the care provided by health and social intervention workers, there is an urgent need for attentive management for in-service training aimed at facing conjugal violence. This premise has already been encouraged since the implementation of the Brazilian National Policy to Tackle Violence Against Women (Política Nacional de Enfrentamento à Violência contra as Mulheres), in 2011, which has prevention, assistance and coping as structuring axes, assuming grievance as an object belonging to the health sector, which should liaise with the other services of the Service Network with the aim of guaranteeing women’s rights.(¹⁶)

However, despite the institutional responsibility to provide permanent training on laborious topics, which are difficult to approach, such as the case of marital violence, this does not exempt professionals from the responsibility of autonomously seeking improvement. Thus, it is inferred that the recognition of the inability to address the issue of violence against women, as shown by the outcomes, can have a positive effect if, in addition to this, a search to improve care is implemented. This is because, in view of this diagnosis, individual training and improvement plans can be drawn up with the purpose of professional qualification, which would contribute to, in the face of adversity, increase the skills to act and not refrain from doing it. Ordinance 2,436, of September 21, 2017, recommends that healthcare professionals must take responsibility for their training and develop strategies for the qualification of their workforce in partnership with the management.(¹⁷)

It is worth pointing out that professionals can be held liable, in the civil and criminal spheres, for damages resulting from poor assistance. This situation, defined as malpractice, is included in the codes of ethics of different healthcare professions, such as the medical and nursing categories.(¹⁸,¹⁹) With this, more than a motivation, seeking to train oneself to act in the face of emerging phenomena of the assisted community is configured as a legal obligation. This situation is essential to promote care based on theoretical-scientific knowledge and thus reduce the damage resulting from ineffective care.

Although also related to the lack of preparation to deal with the issue, the feeling of impotence to act in situations of domestic violence still emerges. This inertia of professionals is related to deep factors of social construction, in which situations of violence are understood as restricted to the private sphere, and should only be resolved by the couple or within the scope of legal-police institutions, as indicated by a study carried out in Santa Catarina.(⁸,²⁰) Thus, as a sociocultural construction, a national study shows the greater acceptance of violence, especially against people with a female gender identity.(²¹) This belief is also shared by healthcare professionals, which leads to non-investigation of marital daily life, seen as a space of intimacy for the couple, compromising attention to face the problem.

Another situation unveiled by the study, which tends to further delay the process of breaking up the abusive relationship, concerns professionals’ conduct of indifference to the situation of violence. The seriousness of this attitude is associated with lack of preparation and an attitude of disregard in the face of repercussions of the experience of abuse on women’s lives and health. This situation was evidenced in a Swedish research carried out with 30 healthcare professionals who reported indifference related to the feeling of individual insecurity with the subject.(¹⁵) This conduct directly affects the health of those assisted, and the involvement of management is essential, in order to broaden the perspectives of action and promote behavioral changes in the workforce.

Given the above, the findings reveal the interface between the lack of care and the permanence of women in the relationship, an event that makes them vulnerable to new situations of violence. Corroborating this fact, a study carried out with 15 healthcare professionals in Paraíba shows that, when professionals do not intervene in this circumstance, it favors the perpetuation of violence.(²²) The same situation was reported in surveys conducted with healthcare professionals in South Africa and the United States, which reported that the lack of knowledge about how to act limits care and contributes to women’s permanence in relationship, consequently exposing it to new violent situations(²³,²⁴) – situation also unveiled in our study.

Associated with remaining in an abusive relationship, the study warns that, in the face of non-care, women are susceptible to physical and mental illness, including suicide attempts. In this sense, the Pan American Health Organization highlights that women inserted in a context of intimate partner violence are almost twice as likely to have problems with alcohol, depression, attempted suicide and suicide.(¹) Confirming this information, a study carried out with 11 Palestinian women points out that the experience of this problem promotes hopelessness in their lives, making them consider limiting their own lives.(²⁵)

Although this is not a finding of this study, it is important to point out that, in addition to falling ill and the risk of suicide, women who do not have support are also more susceptible to femicide. This situation can be evidenced by a study released in 2019 that shows an increase in mortality rates from femicide over the years.(²⁶) Another study pointed out that circumstances such as social distancing due to Covid-19 have made women even more vulnerable to death.(²⁷) Therefore, the participation of nursing professionals is highlighted to support women in coping with this problem, and their practice may affect the reduction of morbidity and mortality rates due to this problem.(²⁶)

The study draws attention to the fact that professionals, when referring to the consequences related to care, especially the commitment to health and the risk of death, adopt a position of impersonality, transferring to the other the responsibility for negligence in care. This may be related to a subconscious attempt to evade responsibility for care not provided to women. This not looking at oneself limits the reflection on the implemented inadequate practices, not favoring the improvement and change in the way of acting.(¹¹)

The statements make us realize that this transfer of responsibility does not happen when the results of actions and interactions bring benefits to women. This situation can be observed when professionals who assist users in situations of violence develop their praxis guided by good practices, such as interest in training, awareness, welcoming and sensitive and qualified listening. In these circumstances, the results of actions and interactions are positive, which means the woman does not allow herself to live in a violent relationship. A study carried out in Rio Janeiro, with 16 women who attended the meetings of the Reference Center, found that qualified, respectful and non-judgmental listening by healthcare professionals favors tackling the phenomenon by women.(²⁰)

Professionals reveal that this empathetic way of acting helps to strengthen women so that they can find mechanisms for coping with the experience of violence. This behavior expresses the practice of being with the other, in addition to the company, making evident the feeling of concern for users’ lives and safety. A study carried out with one hundred nurses in a city in Rio Grande do Sul indicated a successful experience in relation to the care provided to women in situations of violence. This way of acting was based on welcoming, support, protection and guidance, emphasizing the articulation with the local support network. Such behaviors also enabled the instrumentalization of women about their rights, contributing to a conscious and effective decision-making in relation to the experience.(²⁸)

It is by referring to this form of care, resolute and based on good practices, that the management must support the construction of its assistance plans. Therefore, it is essential to take into account, in addition to the uniqueness presented by each user, the possible articulations to be established with the different social and institutional actors. A national study carried out with nurses in the Family Health Strategy of Porto Alegre showed that, among the successful strategies used to face violence against women, there is the involvement and articulation with the care network for women in situations of violence.(²⁹)

Within the scope of Primary Health Care, this support can be made available from an organization of services, designed in conjunction with management at different levels of care. It is important to highlight that, in the health area, the work often lacks multiple skills, which are not always dominated by professionals. In this sense, violence presents itself as a complex challenge for professionals, requiring improvement and dialogue with other sectors, decentralizing and expanding practices so that assertive strategies are identified, preventing women from remaining isolated and more vulnerable to offenders, even when accompanied, as this is the condition of women who do not have their needs considered or are neglected.(²⁰)

Conclusion

The study reveals that receiving or not receiving qualified assistance in services impacts on women’s lives, either positively or negatively. The lack of care can reverberate in exposure to recurrent partner aggression, with consequent deterioration for women’s health, and may even result in death. On the other hand, care, when based on welcoming and strengthening of women, provides female empowerment, which contributes to the confrontation of conjugal violence. Thus, comprehensive care is essential for women empowerment, in the sense of breaking the cycle of domestic violence and allowing a life without violence.

Acknowledgments

This work was carried out with the support of the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nivel Superior) - Financing Code 001 - and the Bahia State Research Support Foundation.

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Publication Dates

• Publication in this collection
  26 Nov 2021
• Date of issue
  2021

History

• Received
  21 June 2020
• Accepted
  1 Mar 2021