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Conteúdo (article):

The impacts of violence among women in intimate relationships: an integrative literature review
Authors:
1Fabiana Lobo Mota; Postgraduate Program in Collective Health - UNESP, E-mail: fabiana.lobo@unesp.br; Orcid: https://orcid.org/0000-0003-2080-5685 .
2Margareth Aparecida Santini de Almeida; Botucatu Medical School - UNESP, Postgraduate Program in Collective Health - UNESP, E-mail: margareth.almeida@unesp.br, Orcid: https://orcid.org/0000-0002-4603-2513 .
3Dinair Ferreira Machado, Botucatu Medical School-UNESP, Postgraduate Program in Collective Health-UNESP, E-mail: dinair.machado@unesp.br, Orcid: https://orcid.org/0000-0003-3006-7110 .

Abstract
Objective: To identify cultural, social and health impacts caused by intimate partner violence (IPV) in homoaffective (MOH) and biaffective (MOB) women. Method: This is an integrative literature review that sought and analyzed studies indexed in the PubMed and Lilacs databases, considering the following languages. The study sought to answer the following research question: What impacts does IPV bring to MOB and MOH? 42 studies were found and after applying the exclusion criteria, 19 went into the final sample. Data were analyzed using the content analysis methodology, Bardin\'s thematic analysis modality (2009). Results: The full analysis of the articles revealed two categories of analysis 1) Intimate partner violence and sociocultural impacts; and 2) Intimate partner violence and health impacts. Conclusion: The experience of situations of violence in intimate partnerships between homo and/or biaffective women affect their sociocultural and health dimensions, since they are under the bias of double vulnerability: women in homo/biaffective relationships. There is also an invisibility of the phenomenon in health services, since professionals are not trained to address the different sexual orientations among women and even less the situations of violence resulting from these relationships.
Keywords: violence against women, sexual and gender minorities, IPV, female homosexuals
Introduction
In spite of the fact of being a phenomenon that still requires confrontation and prevention strategies, violence against women by intimate partners in hetero-affective relationships has been explained, denounced and faced daily through scientific literature, by the implementation of public policies of confrontation and protection. Nevertheless, women in homosexual and bisexual relationships also experience situations of violence in intimate partnerships that are usually silenced and hidden in society, needing to be made visible ¹.
As seen under the logic of heteronormativity, women who are already considered inferior, according to the hierarchical order imposed by patriarchy, become a minority sexual group when they are excluded, discriminated and stigmatized for not fitting into the socially accepted norm, i.e., the heterosexual standard. The process of self-acceptance of their sexuality is already difficult for this group, which, most of the times, due to the discomfort of assuming themselves in front of a normative society that is cruel to those who are different, silences the situations of violence they have suffered 2.
The patriarchal structure that operates and shapes behaviors and conventions through hierarchical relations between men and women and the gender asymmetries, when dealing with the areas of production and social reproduction, influences and causes the expressions of violence in intimate relationships 3. The non-heteronormative sexuality is faced as taboo and, therefore, women are seen with prejudice and rejection by society. Women in relationships with women can experience suffering twice: once for the discrimination of their homosexuality and twice, for carrying in secret the aggressions they suffer 2.
Regardless of sexual orientation, women are socialized since birth to play socially molded and structured roles based on their biological sex, i.e., to take care of the house, find a husband, have children, and form a nuclear man/woman family, besides being educated to be passive and not to be protagonists, and to control their sexuality, even if it is heteronormative, since these are not desirable characteristics in a woman. In this sense, throughout their lives, women find it difficult to seek their rights and position themselves before the norms and customs, even more so when it comes to their sexual orientation 2,1.
And in this predominance of heterosexism and heteronormativity, people who are singled out by society as a minority sexual group begin to feel discomfort, not because of their sexual orientation, but because of the awareness that they are constituent parts of a sexual minority that is deeply discriminated and stigmatized – and in that sense, they go through the so-called minority stress².
For those reasons it is necessary to deconstruct the definitions of masculine and feminine roles as being biologically determined and to go on inserting more dynamic understandings, in a social construction of identities and thus incorporating gender in the analysis of violence against women 4,5,6,7,8. Gender is now understood as a category of analysis that allows for the complexification of new possibilities of being, acting, and making changes5,7. It is worth mentioning that this study demarcates as categories of analysis homosexual and bisexual women, respectively, as those who are attracted affectively and/or sexually only to women, and those who are attracted to both men and women.
Given this context, studies that publicize the impacts of intimate partner violence on this group are becoming increasingly imperative. Thus, this study aimed to identify the social, cultural, and health impacts caused by intimate partner violence (IPV) on bi-female (hereinafter MOB) and homoaffective women (hereinafter MOH).
Methods
This is an integrative review study integrating a diversity of methodological perspectives. It combined the sum of theoretical and empirical data, providing a comprehensive understanding of the object of study9,10.
The present review\'s methodological steps were: 1) Identification of the topic and guiding question; 2) Establishment of search strategies and definition of inclusion and exclusion criteria; 3) Definition and categorization of the information of interest to be extracted from the studies; 4) Evaluation, interpretation and synthesis of the studies, containing a descriptive and critical analysis of the main contributions and gaps identified in the literature10. The guiding question of the research was: What impacts does intimate partner violence have on bi-sexual and homosexual women? Data collection included journals indexed in PubMed and Lilacs databases. Searches were directed by controlled descriptors combined with Boolean operators: mulheres OR woman OR abused women OR chicas OR mujeres violadas AND Minorias Sexuais de Gênero OR bissexual OR homossexuais femininas OR lésbicas OR mulheres que fazem sexo com mulheres OR LGTQ OR minorities gender women who have sex with women OR minorías sexuales y de género OR mujer lesbiana OR mujeres que hacen sexo con mujeres OR bisexuales OR bisexuals dissidente AND violência contra as mulheres OR violência doméstica e sexual contra a mulher OR violence against women OR offenses against women OR domestic and sexual violence against women OR intimate partner violence OR violência por parceiro íntimo.
Inclusion criteria were full-text studies in Portuguese, English, and Spanish; studies with empirical results that had been published between January 2011 and December 2021 in PubMed, and those in Lilacs with no time cut. The PubMed database was searched in October 2021, and the Lilacs database was searched in July 2022.
The exclusion criteria were: master\'s dissertations, doctoral theses, book chapters, book, manuals, monographs, editorials, reviews, letters to the editor, comments/critiques, multimedia, repeated articles, and studies that did not include the research object.
According to the indicated criteria, initially 42 publications were found, 35 in the PubMed database and 7 in the Lilacs database.
Of these studies, 19 were included in the final set as shown in Figure 1.
Data analysis was performed according to Bardin\'s content analysis, thematic modality11 (2009).
Figure 1
Table 1

Among the 19 studies analyzed in full, it was observed that 2020, 2017, and 2015 were the years that had the most publications, with four in 2017, representing 21.05%; and three articles in the years 2017 and 2015, representing 15.79% in each year. In the years 2021, 2018, 2016, and 2014 there were two articles in each year, representing 10.52%, and one publication in the year 2022, representing 5.26%. There were no publications between the years 2011 to 2013, even though this period was included in the search method.
As for the language, most studies were in English n=15 (93.75%) and only four studies were in Portuguese (21.05%). As for the country of origin of the first author, most of them came from the United States (n=15), representing 93,75%, only four studies from Brazil. There is a predominance of authors from developed countries in North America. No studies from the Spanish language, or from countries whose language is Spanish, were found, even though there were descriptors in the Spanish language inserted in the method, which suggests the existence of a knowledge gap, requiring investments in research.
The studies were published in journals of multidisciplinary character, owing to the significant deepening in the understanding of the phenomenon, which is complex and involves the intersection of violence in intimate partnership and sexual orientation.
As for the methodology employed in the publications, the predominance of quantitative methods, seeking to prioritize the identification and analysis of the prevalence of violence, the most common types of violence and the outcomes of exposure to the phenomenon of violence in intimate partnerships, as well as the factors that impact it. Increased efforts and investments in qualitative research are needed.
The qualitative method is less frequent, demonstrating a gap, since the phenomenon of violence is better understood when giving voice to the interlocutors involved, and the qualitative method is the one that best gives light to this scenario. Bosi 31 (2012) argues that violence circulates in various scenarios and, for a better understanding, dialogues between researchers and experienced contexts are necessary, in addition to the perceptions that the interlocutors have about their lives.
As shown in Table 1, for the purposes of better visualization and analysis, the articles were grouped according to the objectives achieved and were coded as follows: IMPACSo; IMPACult, and IMPACSau. Thus, after reading the articles in their entirety, two categories of analysis were revealed: 1) Intimate partner violence and sociocultural impacts and, 2) Intimate partner violence and health impacts.
1) Intimate partner violence and sociocultural impacts
The phenomenon of intimate partner violence is complex and its contexts invisibilized, making it unrecognized as a problem to be addressed being thus full of effects and impacts (IMPACult4; IMPACult1). Society brings sociocultural validation for monosexuality, that is, the approval of relationships arising from sexual attractions exclusively for a single gender or sex.
Bisexual women, owing to their non-monosexual sexual attractions, would be less protected and at greater risk of both victimization and perpetration of intimate partner violence when compared to heterosexual and homosexual women. One of the hypotheses raised was that, in addition to suffering stigma and discrimination experienced externally to their relationships, they would be receiving less protection from membership in ideological LGBT groups. In general, membership in gay groups is usually based on sexual identity and not on sexual attraction, giving bisexual women rejection in groups because they have a different sense of themselves. The LGBT social movements do not confer protection by not recognizing this group and therefore, subject them to more violent acts, perpetrated by the lesbian members themselves (IMPACSo2; IMPACSau2; IMPACSau6; IMPACSau8).
In the field of sexuality there is also the cultural aspect linked to the fluctuation of sexual orientations, that is, society tends to validate sexual orientations whose dimensions are stable throughout life. In this sense, women who express flexibility, changing throughout their lives their sexual attractions/practices, behaviors and identity, are susceptible to rejection and repudiation, making them vulnerable to intimate partnership violence (IMPACSau6; IMPACult1).
In addition, there is a cultural belief of mistrust towards bisexuality, inferring that they are people who are incapable of being in monogamous relationships, should romantic pairs so desire. The much-propagated monogamy then becomes the negative bias for women with bisexual identity, because by having interests in maintaining sexual practices with men and/or with women, it is believed that they are not capable of establishing faithful and monogamous affective relationships. (IMPACSo2; IMPACSo1; IMPACSau1; IMPACSau2).
Other socio-cultural impacts arising from intimate partnership violence in homo/bisexual women have been publicized by the studies, one of them is related to the socio-economic burden as millions of women, may, lose paid days of work throughout their lives. Losses of this magnitude impact especially in those countries with high prevalence of violence against women (IMPACSo1 and IMPACult4, IMPACSau1).
Sexual minority status, socio-historical-cultural conditions, and rejections of sexualities are brought as intertwining factors that give women permissive perceptions of intimate partnership violence, making them vulnerable and leading them into a state of insecurity and non-recognition of the experienced violence (IMPACult1; IMPACSau6; IMPACSau8; IMPACSau4; IMPACSo2). In this way, by threatening to reveal to others that the woman is gay or lesbian, it becomes a tactic to control the partnership; highlighting intimate partnership violence to heterosexism. In this scenario, the woman who already receives stigmatizing influences externally remains in the abusive relationship for fear of negative responses from people, institutions, and the work environment (IMPACSau2; IMPACSau6).
Life circumstances filled with discord and hostility instill on women internalized feelings of homophobia and biphobia (IMPACSau6; IMPACSult1; IMPACSau8). This context may contribute to hamper their discernment for the identification of violence, as they already enter into intimate relationships filled with experiences of rejection such as harassment and discrimination, and therefore weakened (IMPACult1; IMPACSau6; IMPACSau8).
Furthermore, there may be a disparity of intimate partnership violence in women who are considered to be from the minority social group compared to heterosexual women, using the minority stress model. Under this logic, not all women would experience the same types of violence and also, they will not experience it equally, as homo/bisexual women would be from a hierarchical point of view even more predisposed to situations of intimate partnership violence, with little or no condition to cope and/or break away from aggression (IMPACSo2; IMPACSo1; IMPACSau1; IMPACSau2).
In addition to the minority stress model, there are others such as the socioecological model and syndemic view, which intersect culture and environment as influencers to the phenomenon of violence (IMPACSau9; IMPACSau10; IMPACult1). There is an intersection of factors such as heteronormative structure, stigma, experiences of intimate partner violence, which put pressure on homo and biaffective women and shape their lives differently than heterosexual women (IMPACSau2; IMPACSau6; IMPACult1).
The status of sexual minorities, enable the so-called "triple jeopardy": situations of suffering as a result of exposure to racism, sexism and heterosexism (IMPACSau2; IMPACSau6, IMPACult1; IMPACSo5). The studies further indicated the need for countries to adopt robust laws and policies, protective and inhibitory to violence against women with involvement to biaffective and homoaffective women (IMPACult4; IMPACSol; IMPACSau1).
2) Intimate partner violence, health impacts
Negative messages about sexuality and/or conflicts over non-heteronormative sexual orientation, often in unfavorable economic conditions, embedded in stigmatized social contexts both in society in general and in the LGBTQI+ community, result in stress and can lead to serious health consequences for this population, such as depression, sadness, anxiety, insomnia, among others (IMPACSau4; IMPACSo3; IMPACult1; IMPACSau6).
Sexual minority stress involves experiences outside of intimate affective relationships such as situations of violence, harassment, and discrimination; and within intimate relationships such as concealment of sexual identity and/or practices; internalized homonegativity, and negative feelings about oneself from stigmatizing experiences (IMPACSo2; IMPACSau10; IMPACSau3; IMPACSo3; IMPACSau6).
Women dread "coming out of the closet" for fear of experiencing prejudiced reactions in their environments, and for fear of disapproval by families, friends, and professionals who welcome them into various protection and care facilities (IMPACSau4). Stressful experiences can exacerbate intimate partner violence, both in victimization and perpetration. There is an increase in vulnerabilities, providing increased risk to the physical and mental health of these women, dysregulating their emotions, enabling less agency, silencing, trauma, and low empowerment (IMPACSau1; IMPACSau10; IMPACSau9).
Negative experiences involving sociocultural dimensions such as homonegativity, heterosexism, monosexism, power inequalities, stigmatization, marginalization, physical and sexual abuse in childhood, and structural violence, among others, are variables that are mostly unchangeable and/or difficult to interfere with. However, there are contexts with high levels of health impacts and that are with modifiable risks, when they involve variables of relationships such as conflict management, personal and relational satisfaction, communicability, conflict resolution skills and that when interfered with can mitigate the phenomenon of intimate partner violence (IMPACSau9; IMPACSo3; IMPACSau3).
These dimensions directly interfere with the amplification of women\'s emotional suffering, leading to irritability and hostility. The studies revealed that compared to heterosexual women, lesbians are more likely to socialize in places such as bars and clubs that promote the abuse of alcohol and other drugs (IMPACSau7; IMPACSo3; IMPACSau7). The negative feelings and alcohol abuse of this group are often related to physical and verbal assaults, increasing the risks for intimate partner violence (IMPACSau7; IMPACSo3; IMPACSo1).
Often the perpetrations of psychological and verbal aggression, dominance, and isolation in these women\'s relationships negatively impact their health, with the onset of common mental disorders such as depression and anxiety, as well as chemical dependency through the abuse of alcohol and other drugs. In addition to mental health instability, physical symptoms also appear such as: trauma; acute injuries; neurological disorders; gastrointestinal disorders; physical problems such as headaches, dizziness, fainting, irritability, alcohol and other drug abuse; chronic fatigue, heart problems, eating disorders such as obesity (IMPACSo3; IMPACSau7; IMPACSo1).
Coercive and risky sexual behaviors were also pointed out by the studies as variables that condition vaginal sex exposures reducing the frequency of condom use and increasing the rates of sexually transmitted diseases (IMPACSo3; IMPACSau7; IMPACSo1; IMPACSau6).
Bisexual women are at higher risk for unintended pregnancy because adherence to contraceptive behaviors may change depending on the sex of their partners during a given time period (IMPACSau6). However, both gay and bisexual women experience psychological distress because of reproductive and sexual health, as they face social pressures to align with heterosexist expectations of relationships and often find themselves involved in unintended pregnancies (IMPACSo3; IMPACSau7; IMPACSo1).
Such conditions have consequences on problems related to reproductive and sexual health, AIDS/HIV, STIs, pregnancy, depression during and after birth, premature births, low birth weight, neonatal death, impaired infant mental health, behavioral problems of delinquency, as well as substance abuse (IMPACSo3; IMPACSau7; IMPACSo1).
The hegemonic culture ends up negatively impacting the sexual health of these women who, by hiding their sexual orientation, end up not disclosing their behaviors and sexual practices to health professionals, undermining the different strategies for disease prevention and care (IMPACSau6). In contrast, homosexual couples who are in civil legal unions usually have already "come out of the closet," and by disclosing their sexual orientations to their employers/employees, favors the inclusion of their partnerships in employer-insured health programs, giving them better health outreach (IMPACSau3; IMPACSau4; IMPACSau5).
The promotion of inclusive institutions, professionals sensitive to the health conditions of homo and bisexual women; preventive services with screenings, risk assessments, planning, cross-cutting support services, integrated community linkages, and a wide range of health programs encourage the adoption of screening practices for intimate partnership violence among homo/bisexual women (IMPACSau1; IMPACSau3; IMPACSau5).
Thus, public health advocates should be vigilant in monitoring and strengthening the entire institutional machinery to address intimate partnership violence against women given the impacts caused on their health (IMPACSau1; IMPACSau3; IMPACSau5). And finally, the studies indicated that due that Latin America presents high rates of gender inequality, violence against women, homo-lesbo-transphobia, there is a need to conduct more critical studies about masculinities and gender, in order to provide profound transformations at political and sociocultural levels that question patriarchy, machismo, and heteronormativity (IMPACSo5; IMPACSau1; IMPACSau3; IMPACSau5).
Discussion
The current literature indicates that women should be conceived as a sociocultural ideological construct with freedom to exercise their sexuality. However, the condition of women with sexual orientation that does not fit heteronormativity predisposes the group to situations of violence in intimate partnership, precisely because they fall short of the policies of confrontation and protection of heterosexual women, composing a minority group 32,26,33,34.
Just as patriarchy imposes gender hierarchies in which women are subjugated and inferiorized in relation to men, heterosexist norms also hierarchize and subordinate sexual practices, favoring the emergence of sexual minorities, composed of groups that, due to their sexual orientation, gender identity, sexual practices, and behaviors, contradict heterosexist norms and become subjugated and inferiorized by the heteronormative patriarchal society.
The patriarchal societal order is also present in homo/biaffective relationships, considering that in an attempt to maintain power and control over her partner, the aggressor often ends up assuming a coercive and violent behavior determined by who is called the "man in the relationship", therefore, the patriarchal culture that established the social gender roles starts to guide the relationships of homo/biaffective women 32,35,26,33,34.
Under this rationale, the experiences of gender inequality, culturally naturalized, lead women to situations in which a subject, for holding greater power, uses acts to either reiterate or expand his power, establishing coercion - which is the expression of violence legitimately implemented by power imbalances, experienced especially by minority groups of women (both homo and bisexual) 32,35,26,33,34.
In addition, the traumas originated during the life trajectory, discrimination and prejudice, in addition to belonging to a group whose sexual orientation is repulsed and rejected, associated with low socioeconomic status and skin color cause power imbalances in the relationship and leave one of the parties vulnerable to violence by the partner. A black woman, migrant, homosexual, coming from a male-dominated cultural background, may live in a more inclusive country but still be subjected to acculturation. They may not recognize the violence experienced and much less the legal consequences of those acts; exposing them to violence, with impacts on their safety and health 20,36.
Thus, social support is a protective factor and can influence the perception of belonging, validation, and how protected the woman feels. Perceived social support can reduce psychological symptoms, being promotional to their mental health 37,16.
The data collected in this review demonstrate the vulnerable condition in which this population finds itself in relation to human, sexual, and reproductive rights. Corroborating what is evidenced by the ‘Brasil sem Homofobia’ (Brazil without homophobia)38 - a program to fight violence and discrimination against LGBT people - in the question that public policies are necessary to fight prejudice and intolerance, considering the consequences in inequities and lack of guarantee of fundamental rights 38,39.
In the health field, it is essential to look at the health needs, as well as the challenges for the qualification of the care provided to this population, which concerns not necessarily the intrinsic characteristics of gays, lesbians, bisexuals, transvestites, and transsexuals, but also the consequences of the representations and meanings that fall upon their sexual practices and lifestyles as deviant from a supposed standard of normality or health implied by the morally prevailing heteronormativity 39.
For those reasons, it is necessary to disassociate sexuality from the notion of reproduction, problematizing sexual health and opening the field to the consideration of different expressions and possibilities of the exercise of sexuality beyond the naturalization of heterosexuality. It means broadening discussions on law and sexuality from the perspective of the universality of human rights 40.
The struggle for a democratic right to sexuality requires the de-medicalization of the discourse and practices regarding sexual and reproductive rights, democratizing the discussion on sexuality beyond the medical-biological bias 39. The expansion of the care networks, through the promotion of equity directed towards the health of groups in vulnerable conditions, propagation of strategies aimed at the implementation of intersectoral actions, participation of social movements, and the carrying out of studies and research on the health situation of this population in confronting violence, prejudice, and discrimination, are necessary for the enactment of justice devices in the guaranteeing of rights 41.
The invisibility of lesbian and bisexual women in health care spaces, as well as the unpreparedness of professionals to assist this population, has been denounced by formal organizations of these segments since the 80s. Over time the demands have been made visible and included by the policies and published in government primers and manuals of guidelines for good practices 42,43.
However, this advance and achievement ceased in 2014, and the subsequent period was marked by obstacles, challenges, and setbacks, and it was observed that the advances of yesteryear were not enough to improve the care offered to lesbian and bisexual women 42,43.
Historically, the movement of these women began to be understood as a social movement in the political field in the 1970s, when the “Grupo Somos” appeared 44,45. However, it had little representation46 when compared to gay men and did not gain strength, so later lesbian women created the Grupo Lésbico Feminista (Feminist Lesbian Group), replaced in 1981 by the Grupo Ação Lésbica Feminista (Feminist Lesbian Action Group) 45.
Since then, the fight for the conquest and guarantee of rights has gained strength, and in 1991 the National Feminist Health Network (RFS in the Portuguese acronym) was created, with demands about women\'s sexual and reproductive rights already in national scope, thus making it possible to discuss themes that were previously neglected, such as domestic, sexual, and racial violence. The nationwide network that integrated non-governmental and governmental organizations was of paramount importance for the construction of public policies in the country for this population 42.
It included agendas that had been raised for years by the lesbian movement, despite being based on international academic productions, some issues permeated the Brazilian context, such as: the lack of training of health professionals to assist lesbian and bisexual women, the mistaken belief that sex between women cannot transmit sexually transmitted infections, exempting them from using condoms during sexual relations, the difficulties in accessing health services and the lack of welcoming according to their sexual orientation, among others 46.
It is worth mentioning that in the political arena the visibility of this group requires constant disputes, as there are advances and setbacks in guaranteeing their rights. One of the obstacles concerns the invisibility of bisexual women, which despite being included in the document of Atenção Integral à Saúde da Mulher (Comprehensive Care of Women\'s Health), still remains invisible in the trajectory of the lesbian movement that claims the lack of identity of this group as to sexuality and also about a certain privilege of this population that could have access to both men and women. There are also the preconceived ideas of bisexuality as being a transitory identity, supposed promiscuity, and the indecision of these women, factors that contribute to delegitimize their identities 47,46.
In this sense, given the different gaps, the document Atenção Integral à Saúde de Mulheres Lésbicas e Bissexuais (Comprehensive Health Care for Lesbian and Bisexual Women) (2014) was created to ensure that this population is addressed in a comprehensive manner, beyond reproduction, but as a woman subject to rights and sexual freedom. The document also brings the importance of training professionals sensitive to the diversity and plurality of sexual orientations, able to welcome the human being, according to their uniqueness and sexual orientation.
Conclusion
The study allowed to integrate different contexts that involve violence against women in intimate partnership in homosexual and bisexual relationships experienced and the impacts of these aggressions throughout their lives.
It was also observed that there are few publications on the subject in the Brazilian context, being the largest volume of them in developed countries, showing that the discussion and concern in facing the problem has already been legitimized in these places, given the greater technological advancement, access to different cultures and information of these countries.
This study found that intimate partner violence reproduces sociocultural and health impacts on women in homo/biaffective relationships and that this demand is invisible in health services. Furthermore, women are perceived according to their capacity for sexual reproduction, with their sexual orientations, exercise of sexuality, and the outcomes resulting from these relationships being left in the background.
Finally, patriarchy and heteronormativity contribute to the fact that homo/biaffective women remain on the margins of society and health services that fail to include them according to their health needs.

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