Are We Asking Too Much of the Health Sector? Exploring the Readiness of Brazilian Primary Healthcare to Respond to Domestic Violence Against Women

Document Type : Original Article

Authors

1 Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil

2 London School of Hygiene & Tropical Medicine, London, UK

3 Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK

Abstract

Background
There is growing recognition of the health sector’s potential role in addressing domestic violence (DV) against women. Although Brazil has a comprehensive policy framework on violence against women (VAW), implementation has been slow and incomplete in primary healthcare (PHC), and little is known about the implementation challenges. This paper aims to assess the readiness of two PHC clinics in urban Brazil to integrate an intervention to strengthen their DV response.
 
Methods
We conducted 20 semi-structured interviews with health managers and health providers; a document analysis of VAW and DV policies from São Paulo and Brazil; and 2 structured facility observations. Data were analysed using thematic analysis.
 
Results
Findings from our readiness assessment revealed gaps in both current policy and practice needing to be addressed, particularly with regards to governance and leadership, health service organisation and health workforce. DV received less political recognition, being perceived as a lower priority compared to other health issues. Lack of clear guidance from the central and municipal levels emerged as a crucial factor that weakened DV policy implementation both by providers and managers. Furthermore, responses to DV lost visibility, as they were diluted within generic violence responses. The organizational structure of the PHC system in São Paulo, which prioritised the number of consultations and household visits as the main performance indicators, was an additional difficulty in legitimising healthcare providers’ time to address DV. Individual-level challenges reported by providers included lack of time and knowledge of how to respond, as well as fears of dealing with DV.
 
Conclusion
Assessing readiness is critical because it helps to evaluate what services and infrastructure are already in place, also identifying obstacles that may hinder adaptation and integration of an intervention to strengthen the response to DV before implementation.

Keywords

References

  1. Devries KM, Mak JY, García-Moreno C, et al. Global health. The global prevalence of intimate partner violence against women. Science. 2013;340(6140):1527-1528. doi:10.1126/science.1240937
  2. World Health Organization (WHO), London School of Hygiene and Tropical Medicine, South African Medical Research Council. Global and Regional Estimates of Violence against Women: Prevalence and Health Effects of Intimate Partner Violence and Non-Partner Sexual Violence. Geneva: WHO; 2013.
  3. Schraiber LB, dos Santos Barros CR, de Castilho EA. Violência contra as mulheres por parceiros íntimos: usos de serviços de saúde. Rev Bras Epidemiol. 2010;13(2):237-245. doi:10.1590/s1415-790x2010000200006
  4. 67th World Health Assembly. Strengthening the Role of the Health System in Addressing Violence, In Particular Against Women and Girls, And Against Children. Geneva: WHO; 2014.
  5. 69th World Health Assembly. Global Plan of Action to Strengthen the Role of the Health System Within a National Multisectoral Response to Address Interpersonal Violence, in Particular Against Women and Girls, and Against Children. Geneva: WHO; 2016.
  6. García-Moreno C, Hegarty K, d'Oliveira AF, Koziol-McLain J, Colombini M, Feder G. The health-systems response to violence against women. Lancet. 2015;385(9977):1567-1579. doi:10.1016/s0140-6736(14)61837-7
  7. Colombini M, Mayhew S, Watts C. Health-sector responses to intimate partner violence in low- and middle-income settings: a review of current models, challenges and opportunities. Bull World Health Organ. 2008;86(8):635-642. doi:10.2471/blt.07.045906
  8. Colombini M, Dockerty C, Mayhew SH. Barriers and facilitators to integrating health service responses to intimate partner violence in low- and middle-income countries: a comparative health systems and service analysis. Stud Fam Plann. 2017;48(2):179-200. doi:10.1111/sifp.12021
  9. Colombini M, Alkaiyat A, Shaheen A, Garcia Moreno C, Feder G, Bacchus L. Exploring health system readiness for adopting interventions to address intimate partner violence: a case study from the occupied Palestinian Territory. Health Policy Plan. 2020;35(3):245-256. doi:10.1093/heapol/czz151
  10. Leung TP, Bryant C, Phillips L, Hegarty K. GPs' perceived readiness to identify and respond to intimate partner abuse: development and preliminary validation of a multidimensional scale. Aust N Z J Public Health. 2017;41(5):512-517. doi:10.1111/1753-6405.12683
  11. Jhpiego, U.S. Centers for Disease Control and Prevention (CDC), World Health Organization. Gender-Based Violence Quality Assurance Tool: Standards for the Provision of High Quality Post-Violence Care in Health Facilities. 2018. http://resources.jhpiego.org/resources/GBV-QA-tool.
  12. Weiner BJ. A theory of organizational readiness for change. Implement Sci. 2009;4:67. doi:10.1186/1748-5908-4-67
  13. Schwarcz LM. Sobre o Autoritarismo Brasileiro. São Paulo, Brazil: Companhia das Letras; 2019.
  14. de Souza PH. Uma História de Desigualdade: A Concentração de Renda Entre os Ricos no Brasil, 1926-2013. 1st ed. São Paulo: Hucitec Editora; ANPOCS; 2018.
  15. Waiselfisz JJ. Mapa da Violência 2015: Homicídio de Mulheres no Brasil. Brasília, DF: Secretaria de Políticas para as Mulheres da Presidência da República (SPM-PR), Organização Mundial da Saúde (OMS), ONU Mulheres, Faculdade Latino-Americana de Ciências Sociais (Flacso); 2015. http://www.onumulheres.org.br/wp-content/uploads/2016/04/MapaViolencia_2015_mulheres.pdf.  Accessed July 22, 2020.
  16. Venturi G, Godinho T. Mulheres Brasileiras e Gênero Nos Espaço Público e Privado: Uma Década de Mudanças na Opnião Pública. São Paulo: Fundação Perseu Abramo: Edições Sesc SP; 2013.
  17. Reichenheim ME, Moraes CL, Szklo A, et al. The magnitude of intimate partner violence in Brazil: portraits from 15 capital cities and the Federal District. Cad Saude Publica. 2006;22(2):425-437. doi:10.1590/s0102-311x2006000200020
  18. Schraiber LB, D'Oliveira AF, França Junior I. Intimate partner sexual violence among men and women in urban Brazil, 2005. Rev Saude Publica. 2008;42 Suppl 1:127-137. doi:10.1590/s0034-89102008000800015
  19. Schraiber LB, D'Oliveira AF, França-Junior I, et al. Prevalence of intimate partner violence against women in regions of Brazil. Rev Saude Publica. 2007;41(5):797-807. doi:10.1590/s0034-89102007000500014
  20. United Nations. Convention on the Elimination of All Forms of Discrimination against Women (CEDAW). United Nations; 1979. https://www.un.org/womenwatch/daw/cedaw/.  Accessed July 22, 2020.
  21. Inter-American Commission on Human Rights (IACHR). Inter-American Convention on the Prevention, Punishment and Eradication of Violence Against Women “Convention of Belem do Para”. http://www.cidh.org/Basicos/English/basic13.Conv%20of%20Belem%20Do%20Para.htm.  Accessed July 22, 2020. Published 1994.
  22. UN. The United Nations Fourth World Conference on Women. “The Beijing Conference.” https://www.un.org/womenwatch/daw/beijing/platform/violence.htm.  Accessed July 22, 2020. Published 1995.
  23. WHO. Addressing Violence Against Women and Achieving the Millennium Development Goals. https://www.who.int/gender-equity-rights/knowledge/who_fch_gwh_05_1/en/.  Accessed July 22, 2020. Published 2005.
  24. García-Moreno C, Amin A. The sustainable development goals, violence and women's and children's health. Bull World Health Organ. 2016;94(5):396-397. doi:10.2471/blt.16.172205
  25. Brasil. Lei Maria da Penha. Lei N 113402006 Que Dispõe Sobre Mec Para Coibir Violência Doméstica E Fam Contra Mulher. Presidência da República; 2006. http://www.planalto.gov.br/ccivil_03/_ato2004-2006/2006/lei/l11340.htm.  Accessed July 22, 2020.
  26. Brasil. Política Nacional de Enfrentamento à Violência Contra as Mulheres. Brasilia: Presidência da República. Secretaria Especial de Políticas para Mulheres-SPM; 2007.
  27. Brasil. Política Nacional de Enfrentamento à Violência Contra as Mulheres. Brasilia: Presidência da República. Secretaria Especial de Políticas para Mulheres-SPM; 2011. https://www12.senado.leg.br/institucional/omv/entenda-a-violencia/pdfs/politica-nacional-de-enfrentamento-a-violencia-contra-as-mulheres.  Accessed July 22, 2020.
  28. Cruz EF, de Almeida HB, d’Oliveira AF, de Lima EF, Lago C, Machado AM. Don’t stay silent: network of female professors against gender violence at University of São Paulo (USP). Annu Rev Clin Psychol. 2018;15(Sex and Power in the University):223-245.
  29. Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances, and challenges. Lancet. 2011;377(9779):1778-1797. doi:10.1016/s0140-6736(11)60054-8
  30. Brasil. Política Nacional de Atenção Integral à Saúde da Mulher: Princípios e Diretrizes. 1st ed. Brasília, DF: Ministério da Saúde; 2004. http://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_mulher_principios_diretrizes.pdf.  Accessed July 22, 2020.
  31. Barsted LL. O progresso das mulheres no enfrentamento à violência. In: Barsted LL, Pitanguy J, eds. O Progresso das Mulheres no Brasil (2003-2010). Rio de Janeiro: CEPIA, ONU Mulheres; 2011:346-382.
  32. Schraiber LB, d’Oliveira AF, Franca-Junior I, Strake SS, de Oliveira EA. Violence against women: spontaneous demands v. screening in healthcare centers. Saude Soc. 2000;9(1-2):3-15. doi:10.1590/s0104-12902000000100002
  33. Schraiber LB, d'Oliveira AF, Franca-Junior I, Pinho AA. Violence against women: a study in a primary healthcare unit. Rev Saude Publica. 2002;36(4):470-477. doi:10.1590/s0034-89102002000400013
  34. Schraiber LB, d’Oliveira AF, Hanada H, et al. Violence experienced: the nameless pain. Interface-Comunicação, Saúde, Educação. 2003;7(12):41-54. doi:10.1590/s1414-32832003000100004
  35. Ludermir AB, Schraiber LB, D'Oliveira AF, França-Junior I, Jansen HA. Violence against women by their intimate partner and common mental disorders. Soc Sci Med. 2008;66(4):1008-1018. doi:10.1016/j.socscimed.2007.10.021
  36. Brasil. Lei No 10.778/2003 Estabelece a Notificação Compulsória, No Território Nacional, Do Caso de Violência Contra a Mulher Que for Atendida Em Serviços de Saúde Públicos Ou Privados; 2003.
  37. Batista KBC, Schraiber LB, d'Oliveira AF. Health administrators and public policies to deal with gender violence against women in São Paulo, Brazil. Cad Saude Publica. 2018;34(8):e00140017. doi:10.1590/0102-311x00140017
  38. Pessoto UC, Heimann LS, Boaretto RC, et al. Health care services utilization and access inequalities in the Sao Paulo Metropolitan Region. Cien Saude Colet. 2007;12(2):351-362. doi:10.1590/s1413-81232007000200011
  39. Schraiber LB, d'Oliveira AF, Couto MT, et al. Violence against women attending public health services in the metropolitan area of São Paulo, Brazil. Rev Saude Publica. 2007;41(3):359-367. doi:10.1590/s0034-89102007000300006
  40. Marinheiro AL, Vieira EM, de Souza L. Prevalence of violence against women users of health services. Rev Saude Publica. 2006;40(4):604-610. doi:10.1590/s0034-89102006000500008
  41. World Health Organization (WHO). Strengthening Health Systems to Respond to Women Subjected to Intimate Partner Violence or Sexual Violence: A Manual for Health Managers. Geneva: WHO; 2017.
  42. Colombini M, Mayhew SH, Ali SH, Shuib R, Watts C. An integrated health sector response to violence against women in Malaysia: lessons for supporting scale up. BMC Public Health. 2012;12:548. doi:10.1186/1471-2458-12-548
  43. Sheikh K, Ranson MK, Gilson L. Explorations on people centredness in health systems. Health Policy Plan. 2014;29(Suppl 2):ii1-5. doi:10.1093/heapol/czu082
  44. Bardin L. Análise de Conteúdo. Lisboa: Edições; 2004:70.
  45. Miles MB, Huberman AM. Qualitative Data Analysis: An Expanded Sourcebook. 2nd ed. Thousand Oaks: SAGE Publications; 1994.
  46. Schraiber LB. Healthcare needs, public policies and gender: the perspective of professional practices. Cien Saude Colet. 2012;17(10):2635-2644. doi:10.1590/s1413-81232012001000013
  47. Secretaria Municipal da Saúde de São Paulo, Coordenação de Desenvolvimento e Gestão Descentralizada. Projeto Resgate Cidadão; 2003.
  48. Secretaria Municipal da Saúde de São Paulo, Coordenação de Desenvolvimento de Programas e Políticas de Saúde. Caderno de violência doméstica e sexual contra a mulher; 2007.
  49. Secretaria Municipal da Saúde de São Paulo, Área Técnica de Cultura de Paz, Saúde e Cidadania, Coordenação da Atenção Básica. Revista Tecendo Redes de Paz. São Paulo: Planform Gráfica; 2007.
  50. Secretaria Municipal da Saúde de São Paulo, Área Técnica de Cultura de Paz, Saúde e Cidadania, Coordenação da Atenção Básica. Documento norteador para a atenção integral às pessoas em situação de violência do município de São Paulo; 2012.
  51. Secretaria Municipal da Saúde. Linha de Cuidado Para Atenção Integral à Pessoa Em Situação de Violência. São Paulo: Secretaria Municipal da Saúde; 2015.
  52. Brasil, Departamento de Ações Programáticas Estratégicas. Prevenção e tratamento dos agravos resultantes da violência sexual contra mulheres e adolescentes: norma técnica; 2011.
  53. Brasil, Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento de Análise de Situação de Saúde. Viva: Instrutivo de Notificação de Violência Doméstica, Sexual e Outras Violências. Brasília: Ministério da Saúde; 2011.
  54. Gear C, Eppel E, Koziol-Mclain J. Exploring the complex pathway of the primary health care response to intimate partner violence in New Zealand. Health Res Policy Syst. 2018;16(1):99. doi:10.1186/s12961-018-0373-2
  55. Evans DP, Shojaie DZ, Sahay KM, DeSousa NW, Hall CD, Vertamatti MAF. Intimate partner violence: barriers to action and opportunities for intervention among health care providers in São Paulo, Brazil. J Interpers Violence. 2019:886260519881004. doi:10.1177/0886260519881004
  56. Guedes A, Bott S, Guezmes A, Helzner JF. Gender-based violence, human rights, and the health sector: lessons from Latin America. Health Hum Rights. 2002;6(1):177-193. doi:10.2307/4065320
  57. Keynejad R, Semrau M, Toynbee M, et al. Building the capacity of policy-makers and planners to strengthen mental health systems in low- and middle-income countries: a systematic review. BMC Health Serv Res. 2016;16(1):601. doi:10.1186/s12913-016-1853-0
  58. Kwamie A, van Dijk H, Agyepong IA. Advancing the application of systems thinking in health: realist evaluation of the Leadership Development Programme for district manager decision-making in Ghana. Health Res Policy Syst. 2014;12:29. doi:10.1186/1478-4505-12-29
  59. Joyner K, Mash R. Recognizing intimate partner violence in primary care: Western Cape, South Africa. PLoS One. 2012;7(1):e29540. doi:10.1371/journal.pone.0029540
  60. d’Oliveira AF, Pereira S, Schraiber LB, et al. Obstacles and facilitators to primary health care offered to women experiencing domestic violence: a systematic review. Interface-Comunicação, Saúde, Educação. 2020;24:e190164. doi:10.1590/interface.190164
  61. Signorelli MC, Taft A, Pereira PPG. Domestic violence against women, public policies and community health workers in Brazilian Primary Health Care. Cien Saude Colet. 2018;23(1):93-102. doi:10.1590/1413-81232018231.16562015
  62. Goicolea I, Marchal B, Hurtig AK, Vives-Cases C, Briones-Vozmediano E, San Sebastián M. Why do certain primary health care teams respond better to intimate partner violence than others? a multiple case study. Gac Sanit. 2019;33(2):169-176. doi:10.1016/j.gaceta.2017.10.005
  63. Watt N, Sigfrid L, Legido-Quigley H, et al. Health systems facilitators and barriers to the integration of HIV and chronic disease services: a systematic review. Health Policy Plan. 2017;32(Suppl 4):iv13-iv26. doi:10.1093/heapol/czw149
  64. Terra MF. Gênero e Direitos Humanos na Assistência às Mulheres em Situação de Violência Doméstica de Gênero na Atenção Primária à Saúde. São Paulo: Programa de Medicina Preventiva; 2017. doi:10.11606/T.5.2017.tde-01082017-092540
  65. World Health Organization (WHO). Putting Women First: Ethical and Safety Recommendations for Research on Domestic Violence Against Women. Geneva: WHO; 2001. https://www.who.int/gender-equity-rights/knowledge/who_fch_gwh_01.1/en/.  Accessed July 22, 2020.
International Journal of Health Policy and Management
Volume 11, Issue 7
July 2022
Pages 961-972

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History

  • Receive Date: 01 May 2020
  • Revise Date: 14 November 2020
  • Accept Date: 15 November 2020
  • First Publish Date: 08 December 2020

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