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Fatores que interferem na abordagem da violência por parceiro íntimo na atenção primária à saúde: revisão de escopo
Factors that interfere with the approach to intimate partner violence in
primary health care: scoping review

Ana Keila Soares, Universidade Federal de Santa Catarina, anakeilasoaress@gmail.com , https://orcid.org/0000-0001-5961-3731
Fernanda Cornelius Lange, Universidade Federal de Santa Catarina, fernandalange@yahoo.com.br , https://orcid.org/0000-0002-9037-6233
Sheila Rubia Lindner, Universidade Federal de Santa Catarina, sheila.lindner@gmail.com , https://orcid.org/0000-0001-9724-1561



RESUMO

O presente estudo busca responder à pergunta: Como a literatura apresenta a abordagem, na Atenção Primária à Saúde, da violência por parceiros íntimos contra a mulher com objetivo de analisar os fatores que interferem na abordagem da violência contra as mulheres provocadas por parceiros íntimos pela Atenção Primária à Saúde. A metodologia foi baseada na construção de uma revisão de escopo, com estratégia de busca aplicada nas bases de dados: CINAHL, Embase, Lilacs, Pubmed/MEDLINE, Scielo, Scopus, Web of Science e na literatura cinzenta. Foram selecionados 46 estudos sobre a abordagem da violência por parceiros íntimos contra a mulher, na Atenção Primária à Saúde. Os resultados apontam que o contexto de trabalho na Atenção Primária não tem favorecido a abordagem de temas complexos como a violência por parceiro íntimo contra a mulher. Foram apontados como fatores que interferem na abordagem da violência, a sobrecarga dos serviços, a limitação de tempo para atendimentos aos usuários, a imposição do comprimento de metas moldadas pela lógica da produtividade e a alta rotatividade dos profissionais.

Violência de gênero, Violência por parceiro íntimo, Violência doméstica, Atenção Primária à Saúde.

ABSTRACT

This study seeks to answer the research question: “How does the literature present the Primary Health Care approach to intimate partner violence against women?”, with the objective of analyzing the factors that interfere with this approach. The methodology was based on the construction of a scoping review, where the search strategy was applied in the databases: CINAHL, Embase, Lilacs, Pubmed/MEDLINE, Scielo, Scopus, Web of Science and gray literature. 46 studies related to the approach to this type of crime in Primary Health Care were selected. Studies indicate that the work context in Primary Care has not favored the approach to complex issues such as this violence. The overload of services, the limited time for providing services to users, the imposition of target lengths shaped by the logic of productivity and the high turnover of professionals were highlighted.

Keywords: Gender-Based Violence, Intimate Partner Violence, Domestic Violence, Primary Health Care.

INTRODUCTION
Looking at the trajectory of humanity, the constancy of violent events is noticeable, proving that this behavior is fundamentally a social problem, and some of its impacts are quite evident while others are deeply rooted in the social, economic and cultural fabric of human life1,2,3. From this perspective, violence against women should be understood as gender-based, which represents inequality in the exercise of power in contemporary marital relations, and is an explicit representation of violation of human rights4, 5, 6, 7, 8, 9 .
The most common form of violence against women is that committed by their intimate partner. An example of this can be evidenced in the research report, “Visível e invisível: a vitimização de mulheres no Brasil” [Visible and invisible: the victimization of women in Brazil]. Published in 2021, it stated that one in four women over 16 reported having suffered violence, and of that number, 72.8% reported that the perpetrator was known, mainly current or former partners, 25.4% and 18.1%, respectively10. According to the 2022 “Anuário de Segurança Pública” [Public Security Yearbook], in 2021, there were at least 3 femicides per day in this country, representing a 44.3% growth since 2016. The Yearbook showed that, in the case of femicide, the main culprit is the companion/ex-partner (81.7%), and the commonest place, the home (65.5%) 11.
Violence by an intimate partner (VIP) has serious consequences for the health of those who experience it, there being a positive association between a history of violence and health symptoms. Women with a history of suffering VIP are significantly more likely to report bad general health, and, in cases of physical and/or sexual violence, are significantly more likely to consider suicide12.
Even knowing the repercussions for health, historically, the public security and justice sectors have borne much of the responsibility to address the theme5, 13, 14. However, the complexity of the phenomenon highlights the need for an approach involving commitment from sectors such as collective health. Thus, Primary Health Care (PHC), representing the basis of the system, is viewed as a fundamental point to compose the coping network. PHC complying with its principles/guidelines, and being attentive to the PHC territories needs, may be able to contribute to community efforts to prevent and tackle the problem when it occurs, providing a qualified approach from the perspective of both the victim and the aggressor, while giving due referral and treatment to cases throughout the country14, 15, 16, 17, 18.
Studies19, 20 have shown that the Basic Health Units (BHU) have been one of the places most sought by women who have suffered VIP, but often seeking them remains implicit. Research conducted in São Paulo city’s PHC identified greater use of the health service by women who experience VIP, also confirming that this greater use is directly related to the severity and repetition of the violence21. However, their invisibility makes the respective administration difficult. Studies indicate that health professionals have had difficulty identifying and addressing VIP1, 20, 8, 13. Often, even when the problem is perceived, it is neglected or naturalized. Apparently, PHC has attended health problems arising from violence, but there have been flaws in addressing this deeply-rooted problem1, 20, 8, 13.
Understanding the explanation of the context, this study aims to analyze the factors that interfere with the approach by PHC to female VIP victims. Given the diagnosis of the need to synthesize the already existing scientific evidence on the subject, it is believed that this is the first step in making it possible to track propositions that boost practical changes in reality, seeking to strengthen the PHC as a space that is also responsible for the approach to VIP cases.
METHODOLOGY
This work is characterized as a scoping review (SR). Such a methodology seeks synthesis of evidence, regardless of source, and has, among other objectives, that of identifying/mapping published knowledge on a particular subject and identifying the main factors related to a concept. It is a sorting protocol-based screening, which must be conducted with methodological rigor by more than one author22, 23.
Thus, this study was systematically developed from the establishment of the previously registered protocol, and published on the Open Science Framework platform, accessible via the link: Osf.io/37TFH and identified by DOI: 10.17605/OSF.io/FJ73Q. To ensure methodological rigor, it was guided by the recommendations of the check version of Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (Prisma-ScR), which contains the criteria to be evaluated and applied in order to conduct a review study24 .
The search strategies were developed in partnership with the University Library of the Federal University of Santa Catarina, using free text and terms MeSH/Decs combined with boolean operators “OR” and “AND”. As an example, the strategy used for the PubMed/Medline database is mentioned as: "Primary Health Care" [Mesh] or "Primary Health Care" OR "Primary Healthcare" OR "Primary Care" OR "basic health care" OR " basic care" OR "basic service" AND "Violence Against Women" OR "Crimes Against Women" OR "Gender-Based Violence"[Mesh] OR "Gender-Based Violence") AND ("Intimate Partner Violence"[Mesh] OR "Intimate Partner Violence" OR "Dating Violence" OR "Intimate Partner Abuse" OR "Domestic Violence"[Mesh] OR "Domestic Violence".
The databases chosen were CINAHL, Embase, Lilacs, Pubmed/MEDLINE, Scielo, Scopus and Web of Science. The research also included the following gray literature bases: Proquet, Google Scholar and Brazilian Library of Theses and Dissertations (BLTD). Regarding the latter literature, the first 100 links (classified by importance) were collected. There was no date constraint for the studies, nor was there any sample size limitation.
The methodological route was conducted according to that proposed by Arksey and Omalley23, which consisted of the following 5 stages:
Stage 1: Identification of the Research Question.
Marked by the protocol mentioned earlier, the study sought to answer the following research question: How does the literature present the Primary Health Care approach to violence against women committed by intimate partners?
Stage 2: Identification of Relevant Studies.
Performed by applying the search strategy in the respective databases on 08/02/2023. All the articles found were archived in the EndNotes® reference manager. In total, 1,238 studies were captured. Of these, 385 duplicate studies marked on this same platform were removed (Figure 1).
Figure 1

Stage 3: Selection of Studies.
For evaluation of studies through the inclusion and exclusion criteria, all the documents were transferred to the Rayyan® reference manager. Moreover, on this platform, the second manual removal of duplicate articles was performed. Altogether, all 245 duplicate documents not flagged in EndNotes® were identified. Thus, of the total of 630 excluded duplicate studies, 608, thoroughly evaluated, remained.
For the purpose of evaluation, the following inclusion criteria were utilized:
A) Studies related to the Primary Health Care approach to VIP against women
B) Studies from the perspective of health professionals concerning the Primary Health Care approach to VIP against women
C) Studies from the perspective of victims about the Primary Health Care approach to
VIP

EXCLUSION:
A) Absence of full study even after attempts to access the document
B) Editorials, letters and reviews
C) Studies that are not about the Brazilian health system
D) Studies unrelated to the Primary Health Care approach
E) Studies unrelated to VIP against women
F) Prevalence studies
G) Related to the context of COVID19 pandemic
H) Studies related to violence against pregnant women
First evaluation stage: Based on the eligibility criteria, two reviewers screened the studies independently by reading titles and abstracts. Divergences were solved by consensus reached in a meeting, where, in case of permanence of disagreement, a third reviewer exercised the choice. 522 studies were then excluded, leaving 86: 1 article was excluded because it was not found, even after attempts at location; 39 articles were excluded by classification as editorials, letters and/or reviews; 278 articles not studies on the Brazilian health system; 83 not directed towards the approach to the PHC; 22 not related to VIP against women; 84 prevalence studies; and 10 studies in the context of the COVID19 pandemic. 5 documents proved to be duplicates.
Second Evaluation Step: The two reviewers independently read the 86 selected studies in full, based on the eligibility criteria. The divergences were solved again by consensus in a meeting, where, in case of permanence of disagreement, the third reviewer was consulted. In this process, 45 studies were excluded, resulting in a final number of 41.
Of the total exclusions: 4 were excluded because they were not found in full even after attempts to locate them; 3 were excluded by falling into the editorials, letters and/or reviews category; 11 were not studies on the Brazilian health system; 11 not directed toward the Primary Care approach ; 4 unrelated to VIP against women; 5 are prevalence studies; and 4 related to violence against pregnant women. There were also 3 studies identified as duplicates.
Once the final list of articles contemplated in the review was obtained, an additional search of the reference list of each of them was performed in order to find possible documents not yet in the final listing obtained by the search strategy. To guarantee the scope of the research, contact was also made with three professionals, postgraduates in Collective Health, with expertise in the theme of violence in the search for articles that had not yet been captured. In this probe, 5 studies were selected, thus reaching the total of 46 documents to compose the review.
Stage 4: Data mapping.
Data analysis was conducted based on the construction of a Microsoft Excel® spreadsheet where the following bibliometric data of the selected articles were collected: title, authors, keywords, collection methodology and data analysis, study type, review, publication year, research location, objective, and population studied .
For in-depth analysis of the articles’ findings, the analytical category, “Factors that interfere with the VIP approach” was determined. Thus the Excel® spreadsheet was fed with the groupings of information and syntheses of content of the studies that corresponded to the chosen category. The process of analysis and discussion of scientific findings was through the data collected at this stage.
Stage 5: meeting, summary and report of results.
After the data collection and analysis, the work proceeded to the construction stage of the results and discussion thereof, which will be described in the following section.
RESULTS AND DISCUSSION
According to the knowledge provided in the studies that comprise the review, several factors interfere with effective approach to VIP. These factors range from individual conditions, which can be dealt with through each team’s work process, to issues of a collective order, determined by social, political and economic conditions, which to be solved need collective movement in the struggle for the rescue and consolidation of a more community, social health model25 (Figure 2).
Figure 2

Among the difficulties encountered in the selected documents, feelings and emotions were often cited by the professionals participating in the research. Fear was constantly reported, especially with regard to retaliation26, 27, 28, 29, 30, 31, 32, 33, where the professional ends up remaining silent, fearful of possible negative repercussions in case of intervention. There was also mention of fear of negative repercussions for the users themselves27, that of the users’ reaction when approached by the professional30, and that of ethically infringing professional confidentiality32.
This finding resembles the study that sought to characterize the violence suffered by nursing professionals in Basic Family Health Units. According to the research, violence is present in the work environment of nursing professionals and consequently generates defensive attitudes, fear and discouragement in such staff34.
A feeling of impotence was also cited in the literature as a cause of the inertia of the professionals28, 31, 34, 36, 37, 38, 39, 40. The reasons linked to impotence varied: the woman\'s lack of will to denounce the situation experienced34, 41; professional unpreparedness28, 36; erroneous notion that cases of violence are private matters; lack of support for the approach on the part of other professionals37; or the feeling of low resoluteness, given that the complexity of the problem makes individual and strictly technical interventions barely effective38.39, 40.
The aforementioned findings corroborate the knowledge published in the Primary Care Manual that deals with mental health. According to the document, the feeling of not knowing what to do causes in health professionals a feeling of impotence, or even propitiates distancing and resistance of the professional to approaching users undergoing psychic suffering45.
The feeling of helplessness39, 42, 43 and disbelief in the potential of the service to address the question25, 27, 44 were also presented in the studies captured, and are directly related to the impotence described above. Health professionals criticized the low investment in the visibility of the problem of domestic violence on the part of municipal administrators, making the staff feel isolated in the approach to the issue27. According to a study conducted in the southern region of Brazil 42, the lack of institutional support makes health professionals suffer along with the users.
In addition to feelings and emotions, the lack of training27, 29, 30, 32, 34, 38, 42, 46, 47, 48, 49, 50, 51, 52 and the professional unpreparedness36, 53, 54, 55, 56, 57 were mentioned by researchers and professionals participating in the studies collected as factors that interfere with the approach to VIP as the staff become insecure to approach a subject over which they do not have mastery34. An example of this is the study captured by the review48 where 61.5% of the participating professionals had not undergone training for the theme. According to some of the authors selected47, 48, 58, this deficiency is present in undergraduate, postgraduate and training for services that do not seem to integrate the theme and sometimes prioritize curativist and biomedical vocational training.
Such findings corroborate a study59 with 32 students from the latest undergraduate semesters in physiotherapy, nursing, dentistry and medicine, where students have been found to have incipient knowledge about identification and conduct in the face of cases of domestic violence against women. Furthermore, a study60 showed the unpreparedness of nursing students in the process of identifying and assisting women who are victims of violence, due to the lack of experience on the subject provided when undergraduates.
As mentioned previously, in addition to the individual issues cited, barriers from the political and economic spheres were also mentioned. These issues feed the feelings experienced by the staff. In several of the studies collected27, 38, 31, 32, 48, 50, professionals pointed out that the work context in PHC has not favored the approach to complex themes such as VIP. It was mentioned there was a lack of time for a qualified approach to the issue due to the sector\'s overload, caused by an exponential increase in demand27, 28, 31, 32, 48, 50.
In one of the researchs58 collected, interviewees reported that the attention provided to users did not occur properly, mainly because the staff were burdened with a high amount of attributions, there was a large number of families under their responsibility and a work process centralized on performance with an excess of bureaucratic activities. Another study captured25 exposed the diagnosis, made by the users themselves, that the staff did not have time to address VIP.
Information that resembles the research carried out in a municipality in the interior of Ceará, where the authors stated that the impositions of municipal and federal administrations related to the fulfillment of goals, exert pressure on the staff to cope with the largest number of users possible, making it impossible for the professional to devote time to listening to narratives about the health interlocutory appeal presented. As a result, the reception of user issues and the active listening of their needs are increasingly scarce practices, with the PHC promoting exclusively prescriptive care 61.
In this sense, it is important to mention that the time limitation is closely related to the logic of productivity, which was also cited recurrently in the references found27, 49, 57. This way of operating gradually imposed on PHC services, where it seeks to evaluate the service provided through quantitative production and indicators that are not sensitive to the reality of users, pressures health professionals to structure a work process much focused on achievement of goals and little focused on the reality of the PHC territory. It is, therefore, impossible to have a professional posture governed by qualified listening and construction of a bond, these being fundamental devices for the creation of a healthy space for an effective approach to VIP.
An example of this is found in the selected study, D\'Oliveira et al.27 , in which the lack of prioritization by municipal administrators regarding the approach to domestic violence was portrayed, albeit agreeing that it generates a serious impact on users\' health. For administrators, there is a clash between competing priorities, and, in this circumstance, domestic violence is no longer a priority. In the scenario in question, the contracts between private non-profit organizations and the government determine payment by evaluating performance measured by indicators (especially the number of consultations) that do not reflect the assumption of problems and solving grave, complex matters such as violence.
The high professional turnover was also cited in numerous documents25.32, 50, 58, 62 as an obstacle to the improvement of assistance provided by PHC. In one of the selected studies57 67, 3% of the respondents had a temporary employment relationship, entailing constant modifications, reflecting on professional dissatisfaction and poor assistance to users58. The non-fixation of professionals directly affects the creation of a bond, the longitudinality of care and the possibility of a consistent approach32,62. This high turnover is a problem that has direct repercussions on the implementation of the FHS, as this model precisely implies expansion and fixation of the staff at municipal level58.
In short, the way the current model of attention is presented emphasizes more and more clinical practice based on signs/symptoms and its medicalization, focusing on the disease and making it impossible to assume and approach complex health problems arising from another type of suffering that is required to involve institutional commitment and professional responsibility43. According to Carneiro et al. (2021)51 administrative tactics should be considered in the different spheres of government, since, for the approach to violence, there is a need for close relationships that allow construction of paths for their solution. For D\'Oliveira et al. (2022) 27, there must be a pact between administration and service on the importance of approaching the theme in PHC, through, for example, the allocation of time reserved for patients with a domestic violence claim.
FINAL CONSIDERATIONS
It is concluded that the way the work process is set in the PHC territories, subjects such as VIP become secondary and daily life remains centralized on activities focused on achieving goals, with individualized approaches based on attending a conduct complaint. The factors that interfere with the approach to VIP go beyond isolated changes capable of reducing issues such as fear, insecurity and/or professional unpreparedness.
Change of this scenario should be stimulated through the training of professionals who are competent and attentive to claims of violence, but not only this. For a consistent approach to complex, socially-determined topics such as VIP, there is a need for collective movements and in different governmental spheres, in seeking resumption of a less-welfare, medically- centered, less-productive medical care model, less oriented toward stiff indicators and little-sensitive to the realities of the PHC territory, a sanitary model guided by the attributes of a robust PHC, and represented by the Family Health Strategy, where attention turns toward the PHC territory, and health professionals have the safety and the possibility of putting into practice active listening attentive to users, collectively operating in a quest to solve the referred problems.
This study has gaps, among which is the non-evaluation of the quality of the scientific evidence collected, a condition inherent to the proposed methodology. In addition, studies were selected in some of the databases and literature that are possibly gray, which, even with the additional strategies realized, some documents may not have been captured. Despite these points, it is understood that this descriptive, systematic account of the knowledge encountered in the scientific literature is an important step towards understanding the daily life of PHC, in particular, the difficulties faced by the staff who work there.
Acknowledgements
This work was supported by the Higher Education Personnel Improvement Coordination - Brazil (Capes) - Financing Code 001 and also the Santa Catarina State Research and Innovation Support Foundation (FAPESC).
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