Abstract

Violence against women is defined as any act resulting from gender relations that cause death or physical, sexual, psychological, property and moral harm. Comprehensive care requires professionals understanding the support network to guide and refer women victims of violence to services and to value complaints/anxieties. The objective of this study was to identify the scientific production of comprehensive care for women victims of violence. This is an integrative literature review. Data collection was performed via a paired and independent search by two researchers in the Scopus, PubMed, CINAHL, Web of Science, LILACS, BDENF and SciELO databases between January and February 2023. After applying the eligibility criteria and descriptors in health sciences and medical subject headings, ten articles were retrieved. IRAMUTEQ software was used for data analyses. There are great challenges in implementing comprehensive care, and violence against women, as a serious social problem, demands health, education, social assistance and public security policies. The comprehensive actions taken in the care of women victims of violence demonstrate a strong link with the practices of reception and humanization, in addition to an interdisciplinary and intersectoral scope.

Key words:
Violence against women; Completeness; Careful

Introduction

Violence is a multicausal and complex phenomenon that requires the implementation of expanded coping strategies. Therefore, coping with violence requires epidemiological, psychological, social and biological approaches viewed from a social perspective¹1 Fiorini VR, Boeckel MG. Violência interpessoal e suas repercussões na saúde em um hospital de pronto-socorro. Psico-USF 2021; 26(1):129-140.^,22 Oliveira GL, Santos NA, Machado JC, Pires VMMM, Morais RLGL, Rodrigues VP. Violência doméstica contra a mulher na percepção das equipes da estratégia saúde da família. Rev Pesqui (Univ Fed Estado Rio J Online) 2020; 12:850-855..

According to the World Health Organization (WHO), violence is the use of physical force or power, threatened or actual, against oneself, another person, a group or community that causes or will cause suffering, deprivation and even death to any person or species¹1 Fiorini VR, Boeckel MG. Violência interpessoal e suas repercussões na saúde em um hospital de pronto-socorro. Psico-USF 2021; 26(1):129-140.^,33 Santos SC, Barros PA, Delgado RFA, Silva LVL, Carvalho, VPS, Alexandre ACS. Violência contra a mulher: como os profissionais na atenção primária à saúde estão enfrentando essa realidade. Rev Saude Pesq 2018; 11(2):359-368..

Violence against women is defined as any act resulting from gender relations that cause death or physical, sexual, psychological, property and moral harm. In this context, domestic violence against women is a public health problem that affects the social life of the women involved; power relations and gender inequality remain strong influencers in this sphere²2 Oliveira GL, Santos NA, Machado JC, Pires VMMM, Morais RLGL, Rodrigues VP. Violência doméstica contra a mulher na percepção das equipes da estratégia saúde da família. Rev Pesqui (Univ Fed Estado Rio J Online) 2020; 12:850-855..

Data indicate that Brazil is one of the countries with the highest incidence oof violence against women; in a ranking of more than 83 countries, Brazil ranks 5th, behind only El Salvador, Colombia, Guatemala and the Russian Federation. With respect to the Northeast Region of Brazil, there has been an increase in femicide rates, accounting for 79.3% of femicides in the country, thus making it the region with the highest rate of female deaths from violence⁴4 Simoes AV, Machado JC, Soares IGB, Rodrigues VP, Pires VMMM, Penna LHG. Identificação e conduta da violência doméstica contra a mulher sob a ótica dos estudantes universitários. Enferm Actual Costa Rica 2019; 37:95-109..

Over the years, the government has developed policies aimed at guaranteeing the human rights of women in domestic and family relationships to protect them from all forms of negligence, discrimination, exploitation, violence, cruelty and oppression. Law n° 11,340, of August 7, 2006, stands out as an important milestone for combating domestic violence, articulated in an integral and multiprofessional network, permeating actions of the Federal Government, the states, the Federal District, municipalities, and nongovernmental agencies⁵5 Brasil. Presidência da República. Lei n° 11.340, de 7 de agosto de 2006 (Lei Maria da Penha). Diário Oficial da União 2006; 8 ago.^,66 Governo do Estado do Ceará. Secretaria da Saúde. Boletim epidemiológico: violência interpessoal e autoprovocada [Internet]. 2021. [acessado 2023 maio 16]. Disponível em: https://www.saude.ce.gov.br/wpcontent/uploads/sites/9/2018/06/Boletim_Epidemiologico-_Violencia_Interpessoal_Autoprovocada_09042021-1.pdf
https://www.saude.ce.gov.br/wpcontent/up... .

In this context of interconnected care, comprehensiveness is a guiding principle of the Unified Health System (SUS), which seeks to promote the integration of services through care networks. This care requires the use of humane practices to guarantee user accessibility, resolution and/or referrals necessary for cases of violence⁷7 Costa MC, Guzzo PC, Silva EB, Jahn AC. Práticas de saúde aos usuários em situação de violência: da invisibilidade ao (des)cuidado integral. Rev Gaucha Enferm 2014; 35(2):100-105..

Professionals who work directly in the care of victims must understand violence against women in a holistic way, avoiding behaviours that prevent more effective action. Comprehensive care requires professionals understanding the support network to guide women and refer them to services and is an approach that values complaints and anxieties and not only visible marks caused by physical injuries, expanding care to the biopsychosocial-spiritual dimension⁸8 Amarijo CL, Barlem ELD, Acosta DF, Marques SC. Assimilação teórica e prática da violência doméstica: profissionais de enfermagem atendendo vítimas na atenção primária. Rev Enferm UERJ 2018; 26:e33874..

The following question guided this study: what is the main evidence available in the scientific literature on comprehensive care for women victims of violence?

The study of this topic is relevant because it highlights comprehensive care and its importance for coping with domestic violence.

Thus, the aim of this study was to identify scientific methods for providing comprehensive care to women victims of violence.

Method

A systematic search was performed in databases through an integrative literature review following the stages proposed by Mendes et al.⁹9 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm 2008; 17(4):758-764.: identification of the topic to be researched and hypothesis selection, determination of inclusion and exclusion criteria, categorization and evaluation of the studies included in the integrative review, interpretation of the results found and presentation of the review.

To conduct this review, the following mnemonic strategy was considered: P (population: women), V (variables: violence), and O (outcomes: comprehensive care), as shown in Chart 1.

The following guiding question was elaborated: What is the main evidence available in the scientific literature on comprehensive care for women victims of violence?

The data were collected in January and February 2023 via search strategies that combined controlled and uncontrolled Health Sciences Descriptors (DeCS) and Medical Subject Headings (MeSH) interrelated with the Boolean operators AND and OR: Women, “Violence against women”/“women maltreated”, “Integrality in health”, Women, “Violence Against Women”/“Battered Women”, “Integrality in Health”.

The search process was performed in Scopus, PubMed (via the National Library of Medicine), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Literatura Científica e Técnica da América Latina e Caribe (LILACS), BDENF (nursing database) and Scientific Electronic Library Online (SciELO), through the portal of the Coordination for the Improvement of Higher Education Personnel (CAPES) via the proxy server of the Regional University of Cariri-URCA (proxy.urca.br).

The search was performed in a paired and independent manner by two researchers so that there was agreement in the results.

The search strategies were developed on the basis of the specificity of each database or virtual library and are presented in Chart 2.

The inclusion criteria were original articles; studies without a time frame; and studies published in Portuguese, English or Spanish and available in full. The exclusion criteria were repeated and/or duplicated studies in databases, book chapters, doctoral theses, master’s theses, technical reports, brief notes and studies related to other thematic areas.

The survey of studies in each database is described in Figure 1. The initial search revealed 194 studies, and after screening and applying the eligibility criteria, 10 articles remained for exploration of the results and discussion. An adaptation of the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) flowchart was used, as presented by Moher et al.¹⁰10 Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Reprint--preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Phys Ther 2009; 89(9):873-880.

Data processing and analysis were performed via IRAMUTEQ software (Interface de R pour les Analyzes Multidimensionnelles de Textes et de Questionnaires); this R-based software is a free program that allows the processing and statistical analysis of textual information¹¹11 Camargo BV, Justo AM. IRAMUTEQ: um software gratuito para análise de dados textuais. Temas Psicol 2013; 21(2):513-518. and was chosen for its ability to represent the number of words, the average frequency of words and the textual relationship between words.

IRAMUTEQ uses several data processing and analysis techniques, including group specificity research, similarity analysis, descending hierarchical classification (DHC) and word clouds¹¹11 Camargo BV, Justo AM. IRAMUTEQ: um software gratuito para análise de dados textuais. Temas Psicol 2013; 21(2):513-518..

We opted for descending hierarchical classification (DHC) and similarity analysis (SA), which make it possible to identify analytical categories through the material and the cooccurrences between the words and the connectivity between them¹¹11 Camargo BV, Justo AM. IRAMUTEQ: um software gratuito para análise de dados textuais. Temas Psicol 2013; 21(2):513-518..

Notably, the corpora consisted of excerpts taken from the content presented in the results of the selected articles that reported on the self-care of pregnant women and were grouped in abstract format. For corpora formatting, the text was separated by individual command lines and placed in a single text file (.txt). In accordance with Camargo and Justo¹¹11 Camargo BV, Justo AM. IRAMUTEQ: um software gratuito para análise de dados textuais. Temas Psicol 2013; 21(2):513-518., the coding, reading and correction of the corpus were performed to adapt the material to the analytical requirements of IRAMUTEQ.

The results of the studies were hierarchically categorized according to level of evidence (LE) into six categories: level 1, evidence obtained through a meta-analysis of multiple randomized controlled trials; level 2, results obtained from individual studies with an experimental design; level 3, results obtained from quasiexperimental studies; level 4, results obtained from nonexperimental descriptive studies or studies with a qualitative approach; level 5, conclusions obtained through experience reports or case reports; and level 6, scientific statements based on expert opinions¹²12 Stetler CB, Morsi D, Rucki S, Broughton S, Corrigan B, Fitzgerald J, Giuliano K, Havener P, Sheridan EA. Utilization-focused integrative reviews in a nursing service. Appl Nurs Res 1998; 11(4):195-206..

Finally, the discussion was constructed using a descriptive format using relevant findings and literature.

Results and discussion

Ten publications, predominantly of national origin and published between 2007 and 2020, were analysed in this review. Regarding the level of evidence of the studies, there was a predominance of qualitative studies (level 4).

Chart 3 provides a description of the studies included in this review (title; year of publication; database and journal; and methodological design and results).

The general corpus processed by IRAMUTEQ consisted of 10 texts (consisting of the abstracts of the selected articles) separated into 46 text segments (TSs), of which 38 TSs were used (82.61%). A total of 1,626 occurrences (words, forms and terms) were observed, 606 of which were distinct words and 428 of which were hapaxes (words that appeared at least once in the corpus).

The analysed content was categorized into four classes by descending hierarchical classification (DHC), resulting in two classes: Class 1, with 20 TSs (52.63%), and Class 2, with 18 TSs (47.37%). The dendrogram in Figure 2 shows the relationship between these 2 classes, indicating the independence of each.

Class 1, titled “Multiple faces of comprehensive care in approaching women victims of violence”, and Class 2, titled “Public policies versus comprehensiveness in cases of violence against women”, are described below.

Class 1: multiple faces of comprehensive care in approaching women victims of violence

Class 1 comprised 52.63% (f = 20 TS) of the total corpus analysed and was composed of words such as “Attention”; “Approach”; and “Caution”. According to the text segments presented by class, the three main words referred to an interconnected comprehensive care approach and its nuances.

Integrality in health care is one of the main axes of the Unified Health System (SUS), and its relevance involves issues such as meeting the demands according to the needs of individuals, considering their individualities and the dimensions of care in the areas of promotion, prevention, health recovery and rehabilitation, substantial challenges of the health system¹³13 Fontoura RT, Mayer CN. Uma breve reflexão sobre a integralidade. Rev Bras Enferm 2006; 59(4):532-536..

From this perspective, comprehensiveness must be inherent to health facilities, especially with respect to the intersectoral nature of care services for women victims of violence, since this intersectoral articulation can overcome the fragmentation of knowledge and practices^14.15. Violence against women is a serious social problem that demands health, education, social assistance and public security policies.

Therefore, the challenges of comprehensive care can be observed in various agencies that have as their main focus gender approaches since comprehensive care also involves identifying the demands of the victim in each service, with an emphasis on the importance of the knowledge of professionals about referrals in the network and the real effectiveness of the network in human responses to cases of violence¹⁵15 Menezes PRM, Lima IS, Correia CM, Souza SS, Erdmann AL, Gomes NP. Enfrentamento da violência contra a mulher: articulação intersetorial e atenção integral. Saude Soc 2014; 23(3):778-786..

Integrality is inherent to health professionalism and should be within the scope of the actions developed and in daily work. According to Trentin et al.¹⁶16 Oliveira NJ, Silva JMQ, Rosa RFN, Marques PF, Almeida MS, Coelho EAC. Iniquidades sociais e de gênero nas demandas de mulheres por acolhimento. Esc Anna Nery 2022; 26:e20210400., issues such as teamwork, intersectorality itself and personal development issues, such as the commitment of the professional himself or herself, are associated with the effectiveness of actions in the integral context because complex, interdisciplinary topics require multiprofessionality and intersectoriality of care.

However, the same study indicates that even when these assumptions are understood to be necessary for the success of the approach, professionals often face structural limitations and professional training limitations, in addition to practical issues such as underreporting and resistance to attending specific cases, such as sexual violence¹⁶16 Oliveira NJ, Silva JMQ, Rosa RFN, Marques PF, Almeida MS, Coelho EAC. Iniquidades sociais e de gênero nas demandas de mulheres por acolhimento. Esc Anna Nery 2022; 26:e20210400.^,1717 Trenti D, Vargas MAO, Pires DEPP, Hellmann F, Brehmer L, Leal SC. Abordagem a mulheres em situação de violência sexual na perspectiva da bioética. Acta Bioethica 2018; 24(1):117-126..

In this context, the understanding of the role of professionals in cases of domestic violence permeates structural issues and practical action, considering that, in many situations, the assistance offered is based on biological and mechanistic principles of care, which are reinforced by structural and vocational training gaps¹⁸18 Signorelli MC, Auad D, Pereira PPG. Violência doméstica contra mulheres e a atuação profissional na atenção primária à saúde: um estudo etnográfico em Matinhos, Paraná, Brasil. Cad Saude Publica 2013; 29(6):1230-1240..

Accordingly, from the perspective of nursing care for victims of sexual violence, a reflective approach to this practice demonstrates a technicist nature of care, and it is extremely important to encourage comprehensive, welcoming practices on the basis of the principles of humanization and ethical-theoretical values and scientific theories of the profession to strengthen the multiprofessional relationships that integrality can provide ¹⁹19 Morais SCRV, Monteiro CFS, Rocha SS. O cuidar em enfermagem à mulher vítima de violência sexual. Texto Contexto Enferm 2010; 19(1):155-160..

On the basis of reflections in the context of gender and power relations exercised between men and women from a social and cultural perspective, a study sought to provide opportunities for reflective moments through dramatizations with professionals who work in the context of gender violence and the silencing of victims to reinforce the importance of including comprehensive practices in the execution of care. Of the main practices discussed, attentive listening stands out, even in the face of indirect dialogue, where a welcoming attitude and a clinical perspective help in the management of women victims of violence²⁰20 Oliveira CC, Fonseca RMGS. Práticas dos profissionais das equipes de saúde da família voltadas para as mulheres em situação de violência sexual. Rev Esc Enferm USP 2007; 41(4):605-612..

In the context of attentive listening and the precepts of welcoming, comprehensiveness must be considered not only in everyday situations but also in sectors that are sometimes neglected. As an example, it is worth mentioning the reality of women who are victims of violence and who live in rural areas²¹21 Costa MC, Lopes MJM. Elementos de integralidade nas práticas profissionais de saúde a mulheres rurais vítimas de violência. Rev Esc Enferm USP 2012; 46(5):1088-1095.^,2222 Arboit J, Costa MC, Silva EB, Colomé ICS, Prestes M. Violência doméstica contra mulheres rurais: práticas de cuidado desenvolvidas por agentes comunitários de saúde. Saude Soc 2018; 27(2):506-517..

The dynamics of care in this context involve several actors in care practice, such as CHAs, who are key players in strengthening the bond and in the identification of current or potential situations related to gender violence. Among the main practices developed by these professionals, care through relational actions such as bonding (interpersonal relationships), attentive listening, dialogue, health guidelines, and the promotion of the bond between professionals, users and health services²²22 Arboit J, Costa MC, Silva EB, Colomé ICS, Prestes M. Violência doméstica contra mulheres rurais: práticas de cuidado desenvolvidas por agentes comunitários de saúde. Saude Soc 2018; 27(2):506-517..

In consensus, in addition to the CHAs, the doctors, nurses, psychologists and other professionals aware of the reality of each region should make use of the most diverse possibilities within the field of integrality to guide reception, relational practices, discussions and planning of care, and collective actions, as well as the implementation of the expanded clinic as a facilitator of interdisciplinary care in the context of gender violence²¹21 Costa MC, Lopes MJM. Elementos de integralidade nas práticas profissionais de saúde a mulheres rurais vítimas de violência. Rev Esc Enferm USP 2012; 46(5):1088-1095..

Notably, to combat violence against women, it is necessary to integrate knowledge produced in the various sciences. Gender violence is a sensitive topic that addresses the violation of women’s rights and has its origins in multiple determinants and its roots in the sociohistorical and cultural construction of asymmetrical power relations between genders. Facing this problem depends on the awareness of individuals, families, communities and society in general so that the values of patriarchal culture can be deconstructed in all social spaces where violence against women is constructed, naturalized and legitimated. It is necessary that the gender focus is incorporated in the construction of public education, health, social assistance and public security policies so that it is possible to promote the construction of human relationships that do not violate the human rights of women¹³13 Fontoura RT, Mayer CN. Uma breve reflexão sobre a integralidade. Rev Bras Enferm 2006; 59(4):532-536..

On this basis, it is necessary to reflect on the main public policies linked to the integrality of the assistance provided in cases of violence against women, a theme that emerged in class 2 of the analytical corpus.

Class 2: public policies versus comprehensiveness in cases of violence against women

Class 2 comprised 47.37% (f = 18 TS) of the total corpus analysed and was composed of words such as “Public” and “Political”. According to the text segments included in the class, the two main words refer to public policies and their relationships with aspects of comprehensive care in the sphere of gender violence.

Public policies aimed at women’s comprehensive health care include objectives that involve aspects of gender violence, with the principles of the SUS as a guideline. Its practical implementation is of paramount importance to strengthen actions and comprehensive care in the most diverse sectors aimed at the public in question, including the social, health, legal and criminal spheres²³23 Pinto LSS, Oliveira IMP, Pinto ESS, Leite CBC, Melo AN, Deus MCBR. Políticas públicas de proteção à mulher: avaliação do atendimento em saúde de vítimas de violência sexual. Cienc Saude Colet 2017; 22(5):1501-1508..

Among the challenges is the materialization of the assumptions of networking, such as horizontality and the confrontation of power relations existing between different policies and sectors. One possibility is the articulation of professionals from different areas of knowledge in meeting the complexity of the demands of women in situations of domestic violence²⁵25 Aguiar JM, D'Oliveira AFPL, Schraiber LB. Mudanças históricas na rede intersetorial de serviços voltados à violência contra a mulher. Interface (Botucatu) 2020; 24:e190486..

Therefore, it is necessary to reflect on policies that can contribute to combating violence against women by providing a) educational actions to increase awareness of the dynamics of violent relationships; b) actions to strengthen and empower individual women, which enable the emancipation of women; c) educational and awareness-raising actions for aggressors to promote behavioural changes; d) group strengthening actions that promote feelings of belonging, mutual respect and support and participation in decision-making contexts of public policies; and by e) strengthening, articulating and mediating networks of services and solidarity networks for the implementation of policies and programs with more assertive primary, secondary and tertiary prevention actions against this serious social phenomenon¹⁷17 Trenti D, Vargas MAO, Pires DEPP, Hellmann F, Brehmer L, Leal SC. Abordagem a mulheres em situação de violência sexual na perspectiva da bioética. Acta Bioethica 2018; 24(1):117-126..

Regarding the orientation of care through the application of assumptions contained in public policies on women’s health, the National Policy for Integral Attention to Women’s Health (PNAISM) serves as a basis for the development of practical care skills such as qualified listening, empathy, and early detection of conflict situations, and plays a role in the intersectoral organization of services, with interdisciplinary action²⁴24 D'Oliveira AFPL, Schraiber LB, Hanada H, Durand J. Atenção integral à saúde de mulheres em situação de violência de gênero: uma alternativa para a atenção primária em saúde. Cien Saude Colet 2009; 14(4):1037-1050..

Historical evolution in the political, social, cultural and assistance components has promoted a reformulation of and improvement in the intersectoral approach, even in the face of the numerous difficulties existing in integrated work. This fact corroborates the need to increasingly understand public policies and current care models for the care of women victims of violence, which is an important agenda for the discussion of this subject ²⁵25 Aguiar JM, D'Oliveira AFPL, Schraiber LB. Mudanças históricas na rede intersetorial de serviços voltados à violência contra a mulher. Interface (Botucatu) 2020; 24:e190486..

In addition to the policies that guide comprehensive care in women’s health, the importance of knowing and discussing the Policy to Combat Violence against Women, laws related to criminal scope such as the Maria da Penha law and the femicide law, in addition to several documents regulating assistance, such as compulsory notification and protocols for assisting women victims of violence, is emphasized.

Similarity analysis

For textual treatment by the software, some definitions were adjusted so that the graph demonstrated the connectivity and relationships between the terms. The following options were selected in the “definitions” tab and later “graphic settings”: scores at the edges, communities and halos, aiming to form groups by affinities, as well as highlighting related terms by colour. In addition, forms with an occurrence above 5 were used to produce the graphic tree.

On the basis of the graphical representation shown in Figure 3, a semantic range can be observed composed of the words violence, health and woman, demonstrating proximity between terms that refer to the identification of variables associated with the approach to comprehensive care in the face of intersectoriality and policy information, reinforcing the context described during the CHD discussion.

Final considerations

The comprehensive actions taken in the care of women victims of violence demonstrate a strong link with the practices of reception and humanization, in addition to permeating the scope of intersectorality, reinforcing the importance of integrating the various services available as well as the existing knowledge in the practice of care.

As a limitation, the study highlights the limited international literature on the subject, making it impossible to obtain a geographical focus on the comprehensiveness of actions and their impact on combating violence against women.

References

Publication Dates

History