This is an exploratory descriptive study with qualitative approach in order to identify factors that interfere in the process of dealing with violence against women. We conducted interviews with representatives of 15 departments participating in the Network of Care for People Experiencing Violence in the city of Salvador, Bahia, Brazil. Data were organized on the basis of thematic analysis of Bardin. The study showed that intersectoral coordination and care services are provided by the factors that interfere in the fight against violence against women. Both elements are related to strengthening the network of care for women victims of violence. The study points out the need to know the powers of other institutions and reaffirms the importance of coordination between them. It also provides the elements that guide the development of coordinated policies and actions to facilitate the process of dealing with violence against women.
Violence against Women; Domestic Violence; Health Care; Intersectoral Action; Nursing
Violence against women is one of the themes of great international concern, not only due to the damage caused to individual and collective health, but also due the impact on morbidity and mortality throughout society which demands, for its prevention and confrontation, coordinated policies and actions that aim to offer comprehensive care for women.
National and international studies indicate the growth of cases of violence against women. The percentage of victims of physical or sexual violence around the world varies between 20% and 75% (Giffin, 1994GIFFIN, K. Violência de gênero, sexualidade e saúde. Cadernos de Saúde Pública, Rio de Janeiro, v. 10, p. 146-155, 1994. Suplemento.). Venturini et al. (2004) show that more than two million women are battered each year. At that time, 43% of these women declared having already been raped by a man. Population studies indicate that women are more vulnerable to suffer violence at the hands of intimate partners or ex-partners than by strangers, revealing a larger exposure of women in households rather than in publics spaces (Schraiber et al., 2002SCHRAIBER, L. B. et al. Violência contra a mulher: estudo em uma unidade de atenção primária à saúde. Revista de Saúde Pública, São Paulo, v. 36, n. 4, p. 470-477, 2002.).
However, there is a difficulty in perceiving domestic violence, because it is connected with the traditional view of the family as a sacred shrine, parent cell and base of social structure (Soares, 1999SOARES, B. M. Mulheres invisíveis: violência conjugal e novas políticas de segurança. Rio de Janeiro: Civilização Brasileira, 1999.). For decades, what was happening within the “home” setting, widely regarded as a private space, was kept silent, promoting the masking of domestic violence and therefore the underreporting of such data. “Invisible to society”, the episodes of domestic violence tend to be repetitive and to become more severe, unless there is an action that interrupts it (Schraiber et al., 2002SCHRAIBER, L. B. et al. Violência contra a mulher: estudo em uma unidade de atenção primária à saúde. Revista de Saúde Pública, São Paulo, v. 36, n. 4, p. 470-477, 2002.). This difficulty of measuring such situations, as well as their magnitude, ultimately hampers prevention and confrontation actions.
In this context, it is imperative that, regardless of the field of work, professionals be able to identify women experiencing violence and refer them, contributing to their empowerment and consequent breaking of the cycle. It is important to point out that women’s multiple demands go beyond the problem solving power of a single sector, which requires a set of intersectoral coordinated actions.
Costa (2004)COSTA, A. M. Integralidade na atenção e no cuidado a saúde. Saúde e Sociedade, São Paulo, v.13, n. 3, p. 5-15, 2004. States that the ideals of completeness composes a process that starts from the formulation of policies by the State to the production of actions and integration between the different institutions and service providers of care and attention to the citizen. In agreement, Mann and Guareschi (2009), consider the public policy as a set of collective actions aimed at ensuring social rights, thus ensuring a high-quality intersectoral performance of the various services.
Considering this situation, we have adopted as object of study the process of addressing violence against women. The study aims to identify elements that interfere in the process of addressing violence against women.
This is a descriptive-exploratory research with a qualitative approach, carried out in services that integrate the Care Network for People in Situations of violence in the city of Salvador, Bahia, Brazil. The Service Guide of Care for Persons in Situations of Violence organizes the services in four areas, namely: police, legal, psychosocial and health.
The police care is the first service sought out by the woman in search of justice, consisting of services directly responsible for receiving complaints of violations and/or offenses, as well as implementing preventive and corrective actions to deploy in order to contain and penalize the perpetrators of violent practices and actions. The judicial care follows the police care to the extent which it is responsible for evaluating and judging, after finding the facts, the infractions and misdemeanors that occurred, being responsible for clarifying, informing and guaranteeing the rights of citizens. Psychosocial attention makes it possible to exercise citizenship through guaranteeing dignified survival conditions, adaptation to new developments, psycho-affective rehabilitation and the search for new life alternatives. Attention to health is related to the prevention, diagnosis and treatment of physical and/or psychological damage arising from experience of violent situations (Aguiar, 2002AGUIAR, C. et al. Guia de serviços de atenção a pessoas em situação de violência. 2. ed. Salvador: Fórum Comunitário de Combate à Violência, Grupo de Trabalho Rede de Atenção, 2002. Disponível em: <http://www.fccv.ufba.br/rede/docs/guia.pdf>. Acesso em: 1 ago. 2012.
Contact with the services was made possible by the support of the Community Forum for Combating Violence (Fórum Comunitário de Combate a Violência - FCCV), created in 1996, with the objective of proposing and monitoring policies and actions aimed at combating violence in the city of Salvador, Bahia, Brazil. It is composed of entities that are public, private, religious, non-governmental, community, and social movements who meet monthly. The FCCV has assisted in the identification process and contact with services. The services were contacted in order to clarify the goals and relevance of the study, through the elaboration and submission of the request letter, in addition to telephone calls, e-mail, fax and letter.
The selection criteria for the services by FCCV took place at random, and among the nominees, four health institutions and two in the police area didn’t respond to the invitation. Thus, 15 services collaborated with study, linked to health care (01 General Hospital); in Police Support (02 Police Stations that Specialize in Assistance for Women- Delegacias Especializadas em Atendimento à Mulher – DEAM); 01 Police Station Specialized in Repression of Crimes Against Teenagers (Delegacia Especializada de Repressão a Crimes contra Adolescentes - DERCA); in Legal Support (01 Public Defender; 01 Court of Domestic and Family Violence; 01 Special Action Group for Defense of Women - Grupo de Atuação Especial em Defesa da Mulher – GEDEM) and Psychosocial Support (01 Shelter; 01 Municipal Council on Women’s Rights; 03 Social Welfare Reference Centers (Centros de Referência de Assistência Social – CRAS); 01 Assistance Service for Persons in Situation of Sexual Violence (Serviço de Atenção às Pessoas em Situação de Violência Sexual – VIVER); 01 Support Group for People with AIDS (Grupo de Apoio a Pessoas com AIDS – GAPA); 01 Assistance Center for Victims of Violence (Centro de Atendimento a Vítimas de Violência – CEAV).
Interviews were used as data collection technique together with a semi-structured form containing the following questions used: Considering women in situations of violence present demands/needs in several areas, how does this service operate to the combat violence against women? What needs to be done for to meet women’s needs?
The project is linked to the doctoral thesis, whose project was approved by the Research Ethics Committee of the Hospital Santo Antônio (n. 31/07), complying with all ethical aspects for research involving humans based on Resolution 196/96 of the National Health Council. In order to ensure the anonymity of the subjects and their respective services, for each interview the name of the service interviewed was assigned.
The data were transcribed in full with the aid of the program Microsoft Word and organized based on Bardin’s content analysis, more specifically Thematic Analysis. This technique consists in discovering the nuclei of meaning that make up communication (Bardin, 2006BARDIN, L. (Org.). Análise de conteúdo. Lisboa: Edições 70, 2006.). Therefore, we initiated the organization of data by reading the interviews through fluctuating reading until reaching the level of densification of its content, allowing us to organize the ideas. In the second step, we focused in the process of coding and categorizing of emerging focuses of the interviews of respondents, unveiling the following categories: intersectoral coordination and comprehensive care.
Results and discussion
The study showed that the intersectoral coordination and attention provided by services are elements that interfere in the fight against violence against women.
The interviews indicate the importance of intersectoral coordination in order to facilitate the process of confronting the abuses against women, as the following extracts illustrate:
We would like to articulate with all services working with the issue on the agenda to improve the assistance and create firmer bonds [...] (General Hospital).
[...] when hospital workers are suspicious of anything, they communicate it and we investigate [...] (DERCA).
In General, to improve joint actions, it is necessary to keep in touch [...] (DEAM 1).
[...] it is necessary to have the awareness that the network presupposes joint efforts and interaction
[...] (DEAM 2).
Kiss et al. (2007)KISS, L. B.; SCHRAIBER, L. B.; D’OLIVEIRA, A. F. P. L. Possibilidades de uma rede intersetorial de atendimento a mulheres em situação de violência. Interface: Comunicação, Saúde, Educação, Botucatu, v. 11, n. 23, p. 485-501, 2007. report that the intersectoral coordination overcomes the fragmentation of knowledge, promoting the resolution of complex social problems, since it permits the interaction between the subjects of various social sectors and therefore of knowledge, powers and desires.
It calls our attention that although only a health institution has been the target of an interview, it is evident the recognition by other services interviewed regarding the implications of violence against women’s health. Such a situation can be illustrated from the extracts below, which also signals to the difficulty of coordination with the health sector, as can be seen below:
[...] even with large demands for hospitals and health centers, we aren’t able to open channels of coordination with those entities [...] (Shelter).
It is necessary to obtain a more effective coordination, primarily with health services, to improve women’s care [...] (Municipal Council on Women’s Rights).
The difficulty of coordination with health institutions can be associated with little perception on the part of the professionals that the experience of violence represents a worsening of individual and collective health. However, studies show that the health sector is the entry point to domestic violence cases, and may be identified during any health care assistance, from those performed in emergency units to those performed in basic care units, from signs and/or physical or psychological symptoms, or even by the revelation of the user. For some scholars, the non-recognition of the phenomenon can be attributed to the difficulty that health professionals have in understanding domestic violence as an inherent demand in their practice (Schraiber et al., 2002SCHRAIBER, L. B. et al. Violência contra a mulher: estudo em uma unidade de atenção primária à saúde. Revista de Saúde Pública, São Paulo, v. 36, n. 4, p. 470-477, 2002.).
In agreement, Galvão and Andrade (2004)GALVÃO, E. F.; ANDRADE, S. M. Violência contra a mulher: análise de casos atendidos em serviço de atenção à mulher em município do Sul do Brasil. Saúde e Sociedade, São Paulo, v. 13, n. 2, p. 89-99, 2004. believe that the support services for women in situations of violence are of fundamental importance to addressing this problem, being indispensable that these be coordinated with health services in order to promote comprehensive care for women.
Specific services were created in recent years in Brazil, targeted at women in situations of violence, such as the women’s defense police stations, shelters and multiprofessional reference centres (Schraiber et al., 2002SCHRAIBER, L. B. et al. Violência contra a mulher: estudo em uma unidade de atenção primária à saúde. Revista de Saúde Pública, São Paulo, v. 36, n. 4, p. 470-477, 2002.). Such services arose from the need to offer better support to women in the police, legal and social areas linked to the health sector. In this sense, the intersectoral coordination is necessary to ensure the health and quality of life of individuals.
The study also signals the importance of having systematic meetings and gatherings in order to overcome the deficiency of inter-sectoral communication, suggesting that these are the strategies that promote the strengthening of the care network for people who are victims of violence:
[...] I suggest that there be more meetings with institutions such as seminars and workshops [...] (1st Court of Domestic and Family Violence).
[...] there needs to be greater coordination, monthly meetings, seminars, meetings with the services, discussion of the cases, exchanging of contacts, telephone numbers so that together we can seek confrontation strategies [...] (CRAS 1).
[...] it is necessary to strengthen the network through Working Group meetings [...] (Public Defender).
The extracts indicate to greater need of socialization of problems, knowledge and ideas that together help the progress and achievements of confronting violence. Therefore, systematic meetings with representatives of different services, which make up the Working Group (Grupo de Trabalho - GT) for addressing violence against women in Salvador (Bahia, Brazil), reveal themselves as alternative to the consolidation of the network of care for women in situations of violence.
These spaces of dialogue act as pillars for the visibility and consequent effectiveness of resolution of the issues relating to violence against women. However, the success of the interaction between sectors of an organization depends on the group of collaborators (human resources) interconnected in favor of common objectives (Kurcgant, 2009KURCGANT, P. et al. Indicadores de qualidade e a avaliação do gerenciamento de recursos humanos em saúde. Revista da Escola de Enfermagem da USP, São Paulo, v. 43, p. 1168-1173, 2009. Número especial.). For the respondents, the shortfall of human resources limits the power of coordination between the network services:
[...] more coordinators/articulators are needed to perform the function of coordination with other services, since the lack of human resources is generating a work overload, interfering directly in the process of coordination [...] (Public Defender).
[...] we have to consider the limits of operation of some services, due to the limit of human resources [...] (VIVER).
The extracts denote the number of working professionals in the services reflects on the difficulty of developing integrated actions with other sectors. For Bellenzani and Malfitano (2006)BELLENZANI, R.; MALFITANO, A. P. S. Juventude, vulnerabilidade social e exploração sexual: um olhar a partir da articulação entre saúde e direitos humanos. Saúde e Sociedade, São Paulo, v. 15, n. 3, p. 115-130, 2006., the work methodology used in the intersectoral service only makes sense when inserted into a network that truly share, among professionals and services involved, the project in progress and the accountability for their actions.
Promoting comprehensive care involves identification of women’s needs, the services which are the responsibility of each agency and referrals in order to contemplate their needs. Such actions are essential to the process of addressing violence against women.
However, the study revealed that many services are still not prepared to deal with the situations of violence against women, as the extracts illustrate:
The services don’t know how to deal with proximity of violence [...] (REGISTRATION CERTIFICATE- Loreta Valadares Reference Center – CRLV)
[...] we seek an orientation to prevent and monitor women in situations of violence [...] (CRAS 2).
To intervene in the phenomenon of violence against women pervades the professional capacity to recognize such experience. It is essential to have the understanding of its complexity, which will facilitate the identification of the various needs, which often exceed the resolution capacity of a single service. Mann and Guareschi (2009) reflect about the term integrality, proposed by the doctrinal principles of the Brazilian Unified Health System (Sistema Único de Saúde - SUS), as assistance of the person in all his needs.
So, we need to develop a holistic perspective for assistance in order to ensure that it is comprehensive, considering the biological and psychological aspects, besides the legal, socioeconomic and police issues.
However, Galvão and Andrade (2004)GALVÃO, E. F.; ANDRADE, S. M. Violência contra a mulher: análise de casos atendidos em serviço de atenção à mulher em município do Sul do Brasil. Saúde e Sociedade, São Paulo, v. 13, n. 2, p. 89-99, 2004. report on the situation of violence against women, institutional interventions are still more associated to the areas of public safety and social assistance; which, in turn, has contributed to the inclusion of this phenomenon in a vicious cycle with little resolution.
Agreeing with the unpreparedness of the services for the reception and referrals of women, Chandra (2002) points out that many professionals are unaware of support services for women in the process of violence, which culminates in the inappropriate referrals and reflects in a fragmented care (Chandra, 2002). Hence, the need for knowledge of services, especially those which already constitute the network of care for women in situations of violence, as shown by the following extracts:
[...] it is necessary that the institutions have greater commitment to meet the role played by other organizations that are part of the network [...] (Municipal Council on Women’s Rights).
There is a great need to enhance the visibility of services for the community as a whole and for partner services [...] (CRAS 2).
The interaction of services is essential for the strengthening of the network and its information [...] (GEDEM).It becomes necessary to explain more about the institutions that make up the network [...] (CEAV).
In the view of Borsoi et al. (2009)BORSOI, T. S.; BRANDÃO, E. R.; CAVALCANTI, M. L. T. Ações para o enfrentamento da violência contra a mulher em duas unidades de atenção primária à saúde no município do Rio de Janeiro. Interface: Comunicação, Saúde, Educação, Botucatu, v. 13, n. 28, p. 165-174, 2009., the greatest difficulty is for professionals to follow up on the situation. Thus, the support an intersectoral network coordinated and systematized is of fundamental importance, with the proper knowledge about the responsibilities of each entity linked to it, in order to ensure full protection to these women through the protection of their citizenship rights of (Borsoi et al., 2009).
The process of interaction between the various sectors that comprise the network will only materialize through obtaining mutual knowledge, which involves information about its skills, assignments, location, internal and external procedures, as well as working hours. According to Njaine et al. (2006)NJAINE, K. et al. Redes de prevenção à violência: da utopia à ação. Ciência & Saúde Coletiva, Rio de Janeiro, v. 11, p. 1313-1322, 2006. Suplemento., the knowledge of the services is configured and determined through the existing flow of information and communication present on the network. Thus, to enable referrals, assistance, and protection of victims of violence, it is necessary to assimilate how the network incorporates partnerships and interconnections.
We observe the need to search for strategies for dissemination of the institutions that make up the Network of Care for victims of violence, by facilitating access to information, and taking the knowledge of these services to the general population. As a vehicle for promotion of this dissemination, you can use the written, spoken and/or televised media, as according to the following extracts:
[...] it needs to be informative: What is the Network? (Municipal Council on Women’s Rights).
[...] I need to know the news and disclosure of participating services in the network ... This process can be done by means of a specific site, periodically updated [...] (General Hospital).
[...] it is necessary to have network dissemination strategies, such as a site, in order to get to know and recognize the institutions that are part of this network [...] (VIVER).
The possibility of formulating a Network-specific site is cited by more than one service and appears as a good alternative in expanding the visibility of services, their expertise, contacts, location and availability. Fast and qualified online access, will enable the knowledge, not only of the components of the network, but also to the population, having in mind that digital inclusion technology has reached a large part of the community, including the most vulnerable groups of society, such as those with low income and low educational level, in which violent acts are more frequently practiced and perpetuated.
To support the discussion, Gomes (2009)GOMES, N. P. Processo de enfrentamento da violência conjugal. 2009. Tese (Doutorado em Enfermagem) - Escola de Enfermagem da Universidade Federal da Bahia, Salvador, 2009. also refers to the importance of conducting dissemination of services participating in the network. The author reports that, for efficiency in dissemination, it is necessary that the professionals operating in these spaces get to know the institutions and their operations, both in legal, police, social areas and in the area of health, with emphasis on community health agents (ACS) for its approximation with the community.
Considering the knowledge about the services, it becomes possible to make referrals to ensure comprehensive care for women in situations of violence, covering the various fields of women’s needs. Such conduct, however, requires continued attention so professionals should also pursue strategies for the follow-up of cases, as show the extracts:
We know the importance of counter reference, and that’s why we do it. We are careful to follow-up on the case. It is necessary not to lose sight of the woman and have a return visit [...] (CEAV).
[...] you need to develop an effective tool for monitoring of referrals [...] (GAPA).
The interviews point out to an even more complex discussion, namely, the monitoring of cases as an essential factor in the comprehensive care for women. The effectiveness of this monitoring takes place in the effectiveness of all the steps that compose it: the recognition of violence on the part of professionals, the appropriate service, referral, as well as the interest and the search for return of the references, seeking in this way to offer a better assistance to women.
In this perspective, it’s worth mentioning the role of professionals working in the family health strategy (Estratégia de Saúde da Família - ESF), that’s because, in most cases, the family health unit (ESF) presents itself as an entry point for these women. In this sense, the family health team should appear as the protagonist in the process of monitoring of women in situations of violence, as it works with an assigned population, secondary to the territorial process, which allows a greater involvement with the community, and consequently the recognition and understanding of their needs. In this context, Garcia (2009) focuses on nursing because of the strategic position in ESF and may contribute in the orientation process of this professional practice.
The study discusses the process of addressing violence against women from the perspective of services which point to the need for intersectoral coordination and qualification of its professionals and including for referrals so that women receive comprehensive care.
The category “Intersectoral Coordination” points out the need for coordination among the services (which are part of the network or not) as a tactic to confront violence against women and reveals the difficulty of articulating, in addition to proposing strategies that make it feasible to create such interaction spaces of knowledge and actions.
The category “comprehensive care”, in turn, points to the perception of the lack of professional preparation for the recognition of violence and/or for the reception and referral of women. Considering the various needs that women experiencing violence present, the study signals that the referral process requires knowledge of the services and their responsibilities.
We point out the importance of management in the process of intersectoral coordination, from the feasibility of the interaction among the various institutions. Hence, the need for spaces for meetings with representatives of different institutions and the discussion of strategies for addressing violence, including the empowerment of women in situations of violence.
The study also revealed that many services do not know how to deal with the situation of violence; do not know the services for referrals and points to the need for greater dissemination of these services in order to assure women have their needs meet. For this, it is necessary to support the various care services: police, social, legal, and income generation, health and housing. Knowledge of the services supports the development of actions with a perspective for prevention, notification, registration, referrals and follow-up of women in situations of violence at all stages, thus promoting the continuity of assistance and the increased credibility of the service.
It is believed that the results of this study might contribute to greater visibility of the issues that hinder the process of caring for women in situations of domestic violence, offering subsidies to contemplate actions and strategies for the prevention and confrontation of the phenomenon.
The study is limited by not making visible the trajectory of women in search of support for the interruption of the violence, as it originates from perspective of professionals working in the services. We signal to the need for research that values the voices of these women and reveals the paths they have traveled, which will facilitate delineating the flow and will guide intersectoral coordination in order to empower women to have lives free of violence.
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- SCHRAIBER, L. B. et al. Violência contra a mulher: estudo em uma unidade de atenção primária à saúde. Revista de Saúde Pública, São Paulo, v. 36, n. 4, p. 470-477, 2002.
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- 1Research financed by the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq).
- Publication in this collection
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02 Aug 2013
05 Aug 2013